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NEPHROCOLOPTOSIS 


LiGAMENTUM   NepHROCOLICUM.       (LoNGYEAR.) 

Illustrating  the   location   of   the   nephrocolic   ligament,    showing   the   right 

cohc"  H^ment"*^  ^-^h*^"  '°-l°"  ^""^  ?,"^"^  '^^  ^^^  peritoneum  and  t1.e  nepA?o- 
cohc  ligament.  The  peritoneum  has  been  drawn  aside  with  a  cord  and 
the  nephrocolic  ligament  is  shown  isolated  and  drawn  away  from  the  ^t  bv 
tn^show  Thl  ^'"''''^f-  ^°'°^-  ./^^^  ^^^^^^  1^^^  ^""^^  turned  half  around  in  order 
unde^The    cecum         "  nephrocolic   ligament,    the    ileum   being   turned 


NEPHEOCOLOPTOSIS 


A  Descriptiox  of  the  Nepheocolic   Ligament   and  its 

Action  in  the  Causation  of  Nephroptosis, 

With  the  Technic  of  the  OpePiAtion  of  Nephrocolopexy, 

in  which  the  Nephrocolic  Ligament  is  Utilized 

TO  Immobilize  both  Kidney  and  Bowel 


BY 

H.  W.  LONGYEAR,  M.  D., 

professor  of  gvnkcologi'  and  abdominal  surgery,  detrf)it  post- 
graduate mkdicau  school;    clinical  professor  of  gynecology, 
detroit  college  of  medicine;    gynecologist  to   harper 
hospital;    consulting   obstetrician   to    the    woman's 
hospital;  ex-president  of  the  American  associa- 
tion  OF   obstetricians  and   gynecologists. 


WITH  EIGHTY-EIGHT  SPECIAL  ILLUSTRATIONS  AND 
A  COLORED   FRONTISPIECE 


ST.  LOUIS 
C.  V.    MOSBY    COMPANY 

1910 


■*'i 


Copyright,  1910,  by  C,  V.  Mosby  Company 


AFFECTIONATELY   DEDICATED    TO    THE   MEMOKY    OF 

MY  FATHER, 
JUDGE  JOHN  WESLEY  LONGYEAR 


FOREWORD. 


This  monograpli  presents  my  views  of  the  subject 
treated,  and  is  not  a  compilation  or  a  historic  treatise, 
mention  being  only  incidentally  made  of  other  opinions 
and  theories. 

I  believe  that  in  the  nephrocolic  ligament  I  have  dis- 
covered the  principal  positive  etiologic  factor  in  nephro- 
ptosis. The  belief  that  a  nephroptosis,  because  of  the 
action  of  this  ligament,  must  always  be  secondary  to  and 
the  result  of  a  coloptosis  (except  when  due  to  trauma), 
and  conseciuenth-'  should  not  be  considered  separately 
from,  but  of  necessity  with,  the  prolapsed  colon,  explains 
my  reason  for  both  the  form  of  the  title  of  the  book  and 
the  etiologic  basis  on  which  the  subject  is  treated. 

My  contention  regarding  this  action  of  the  nephrocolic 
ligament  gives  araison  (Petre  for,  and  assists  materially 
in  proving  the  truth  of,  the  observation  of  Glenard,  viz.: 
"Enteroptosis  without  nephroptosis,  but  never  nephro- 
ptosis without  enteroptosis."  This  fact  being  accepted, 
the  consideration  of  the  subject  of  displaced  kidney  by 
itself,  ignoring  its  cause  and  unavoidable  accompaniment 
in  the  displaced  colon,  would  be  a  serious  pathologic 
error  and  an  omission  of  a  full  statement  of  fact,  which 
would  tend  to  lead  to  the  unsatisfactory  therapeutic  re- 
sults that  have  usually  attended  the  treatment  of  cases 
of  nephroptosis  in  the  past. 

The  terms  "splanchnoptosis"  and  ''enteroptosis," 
while  describing  a  condition  which  may  exist  in  excep- 
tional cases,  give  an  erroneous  idea  of  the  pathology  when 


6  FOEEWORD. 

applied  to  all  cases  of  nephroptosis,  and  tend  to  lead  into 
a  maze  of  uncertainty  and  iridefiniteness  regarding  both 
etiology  and  treatment.  Gastroptosis  may  be  present 
with  a  nephroptosis,  but  not  necessarily  so,  as  is  the  case 
with  a  coloptosis,  and  when  so  present  is  almost  inevit- 
ably a  sequel  to  the  nephrocoloptosis,  and  one  of  the  later 
developments  of  the  pathology.  The  liver  has  no  ana- 
tomic connection  to  be  influenced  by  a  nephrocoloptosis, 
and  hepatoptosis  may  occur  independently  of  any  of  the 
other  conditions. 

To  arrive  at  a  working  basis  for  treatment,  it  is  true 
that  all  of  these  conditions  and  their  relations  to  each 
other  must  be  considered,  but  a  concentration  of  thought 
upon  the  heginning  of  the  involvement  of  the  pathology  is 
necessary  to  such  an  end.  Still  more  misleading  is  it  to 
look  into  the  pathology  no  farther  than  the  loose  kidney. 
I  believe  that  because  of  the  commonly  accepted  and 
erroneous  idea  of  considering  the  displaced  kidney  by 
itself,  the  full  pathological  situation  is  misunderstood, 
as  well  as  the  true  significance  and  value  of  the  symptom- 
atology. It  is  quite  commonly  asserted  by  a  number  of 
authors  that  this  little  body,  when  movable,  can,  by  the 
pressure  of  its  weight,  cause  a  variety  of  serious  dis- 
orders, such  as  a  kink  in  the  colon  by  dragging  it  down, 
uterine  displacements  by  the  right  kidney  falling  upon 
the  organ,  appendicitis  by  its  weight  interfering  with 
circulation,  ovaritis,  salpingitis,  menorrhagia,  metror- 
rhagia, hematocele,  cystitis,  etc.  When  one  considers 
that  the  weight  of  the  kidney  is  only  from  four  to  six 
ounces,  this  all  seems  absurd;  and  when  the  fixation  of  it 
by  the  old  methods — even  when  anatomically  successful 
— so  often  not  only  has  failed  to  relieve  the  numerous 
manifestations  attributed  to  it,  but  has  augmented  them, 
it  is  no  wonder  that  many  physicians  have  become  skep- 


rOEEWORD.  / 

tical  on  the  whole  subject,  and  advise  their  patients  to 
rather  bear  the  ills  they  have  than  fly  to  those  they 
know  not  of. 

Patients  are  often  told  that  the  displaced  kidney  is  of 
little  importance,  and  that  all  that  is  necessary  is  for 
them  to  ''get  fat"  and  they  "will  be  all  right."  That 
is  quite  a  safe  prognosis,  as  these  patients  usually  can  not 
get  fat,  but,  on  the  contrary,  continue  to  lose  flesh,  re- 
gardless of  dietetic  regimen,  tonics,  etc.  These  are  the 
patients  who  may  be  temporarily  benefited  by  the  Weir- 
Mitchell  treatment  of  forced  rest  and  feeding.  They  get 
up  feeling  much  improved,  and  consider  themselves  well, 
but  the  erect  position  soon  causes  a  return  of  the  irrita- 
tion of  the  digestive  organs,  and  consequent  interference 
with  nutrition.  The  fat  fades  away,  and  the  old  drag 
of  colon  on  kidney  and  duodenum  again  begins.  The 
rest  treatment  is  not  to  be  decried  in  these  cases,  but  an 
operation  should  precede  it,  after  which  the  rest  and 
feeding  will  assist  materially  in  making  the  cure  per- 
manent. 

I  was  much  in  the  uncertain  frame  of  mind  mentioned 
when  an  accidental  observation  during  an  appendectomy 
led  to  the  discovery  of  the  action  of  the  tissue  which  I 
call  the  nephrocolic  ligament.  After  this  the  pathologic 
landscape  became  clear,  symptomatology  meant  some- 
thing definite,  and  therapeutic  indications  became  posi- 
tive. 

The  operation  referred  to  took  place  at  the  Solvay 
Hospital,  Delray,  Mich.,  December  3,  1903.  The  patient, 
a  girl  of  16  years  of  age,  had  complained  more  or  less  of 
constant  pain  in  the  region  of  McBurney's  point  and  in- 
creasingly obstinate  constipation  for  over  a  year.  After 
a  thorough  examination  (no  radiograph),  in  which  every- 
thing was  negative,  excepting  a  sensitive  area  in  the  sup- 


8  rOEEWORD. 

posed  location  of  the  cecum  and  appendix,  appendectomy 
was  decided  on.  Both  kidneys  were  normally  placed  and 
in  no  degree  mobile.  At  the  operation  the  cecum,  with 
the  appendix  deformed  by  adhesions  to  itself,  was  found 
in  the  hottoni  of  the  pelvic  cavity.  During  the  manipulation 
it  was  noted  that  the  right  kidney  could  be  pulled  well 
down  into  the  abdomen  by  making  traction  on  the  cecum, 
and,  moreover,  could  be  held  in  the  prolapsed  position  by 
.continuing  the  traction,  so  that  it  was  impossible  to  re- 
turn it  to  its  normal  position  by  counter-pressure  with 
the  finger  inside  the  abdomen.  On  removal  of  the  trac- 
tion, however,  the  kidney  quickly  slipped  up  to  its  normal 
position.  These  observations  led  to  investigations  on 
both  the  cadaver  and  the  living  subject,  with  the  object 
of  ascertaining  what  connection  there  could  be  between 
the  gut  and  kidney  that  was  strong  enough  to  give  such 
a  manifestation.  The  result  was  the  isolation  of  the 
tissue,  which  I  call  the  nephrocolic  ligament,  as  the  only 
union  between  the  gut  and  kidney  which  was  strong  and 
inelastic  enough  to  cause  the  kidney  to  be  so  readily 
pulled  down. 

This  girl's  constipation  continued  to  increase,  and  one 
year  after  the  appendectomy,  reasoning  from  my  previous 
observations,  I  concluded  that  the  torpidity  of  the  bowel 
was  due  to  the  low  position  of  the  cecum,  and  made  a 
nephrocolopexy,  solely  to  relieve  the  constipation.  The 
operation  was  a  marked  success,  and  has  continued  to  be 
so  up  to  a  very  recent  date  (October  17,  1908).  At  this 
operation  the  nephrocolic  ligament  was  found  to  be  long 
and  lax,  which  accounted  for  the  kidney  remaining  in 
place  with  such  a  marked  coloptosis. 

I  believe  that  a  more  general  use  of  the  x-ray,  a  more 
thorough  palpation  technic,  and  a  due  appreciation  of 
their  symptomatology  will  result  in  a  needed  improve- 


FOREWORD.  9 

ment  in  tlie  early  diagnosis  of  these  cases  and  conse 
qnently  in  the  treatment  of  less  of  them  for  neurasthenia, 
intestinal  indigestion,  chronic  appendicitis,  cholelithiasis, 
cholecystitis,  gastric  dyspepsia,  etc.,  and  a  practical  thera- 
peusis  based  on  the  existing  pathology — the  cause ^  and 
not  the  effect — will  then  receive  attention. 

Early  diagnosis  of  these  cases  should  also  insure  the 
proper  treatment  before  the  development  of  symptoms  of 
a  serious  nature,  which  occur  occasionally  in  an  explosive 
manner,  and  at  unexpected  and  inopportune  times.  Such 
a  case  came  under  my  observation  recently:  A  young  lady, 
having  a  well-recognized  nephrocoloptosis,  had  improved 
for  several  months  and  gained  some  flesh  imder  the  use 
of  an  abdominal  band.  She  became  engaged  to  be  mar- 
ried, and  a  date  was  set  and  invitations  issued  for  the 
wedding.  Three  days  before  this  was  to  occur,  while 
packing  a  trunk,  she  was  taken  with  pain  in  the  right 
side,  and  a  well-marked  and  very  severe  attack  of  Dietl's 
crisis  developed,  which  completely  prostrated  her  and 
contuied  her  to  bed  for  several  weeks,  resulting  in  much 
mental  distress  as  well  as  bodily  pain,  and  great  incon- 
venience and  embarrassment  of  all  parties  concerned. 

No  one  can  foretell  the  stage  of  a  nephroptosis  in  which 
torsion  of  the  pedicle  may  occur  and  such  an  attack  be 
precipitated.  Without  fixation  by  surgical  means,  any 
case  is  liable  at  any  time  to  the  accident.  The  attacks 
are  not  only  severe  and  painful  at  the  time,  but,  especially 
when  long  continued,  sequela  of  a  serious  nature  are 
liable  to  develop. 

Diagnosis  of  this  malady  has  not  been  taught  to  stu- 
dents in  any  practical  way  in  the  past,  and  of  recent  years 
teaching  has  been,  at  best,  superficial.  The  use  of  pos- 
ture, palpation,  and  the  x-ray  in  abdominal  diseases 
should  be  as  thoroughly  taught  clinically  as  is  the  phys- 


10  FOKEWORD. 

ical  diagnosis  of  diseases  of  the  chest.  Very  few  general 
practitioners  know  how  to  examine  for  nephroptosis; 
they  do  not  recognize  these  cases,  and  wonder  where 
their  fellow-practitioners  find  so  many.  I  was  asked  re- 
garding this  question,  during  the  reading  of  a  paper  be- 
fore the  Michigan  State  Medical  Society,  by  a  country 
physician  of  large  practice,  who  said  he  had  seen  but  one 
case  in  several  years.  Another  doubted  my  diagnosis  in 
a  case  which  he  had  sent  me,  but  subsequently  demon- 
strated the  fact  of  the  displacement  by  following  my 
written  directions  for  examination. 

I  recently  operated  on  a  case  of  extreme  nephroptosis 
in  a  woman,  who  had  been  suffering  from  severe  neuras- 
thenia and  malnutrition,  and  who  had  spent  the  last  year 
in  a  fruitless  search  for  health,  trying  sanitariums,  osteo  - 
pathic  and  other  kinds  of  treatment.  She  had  been 
examined  by  a  number  of  reputable  physicians,  but  only 
one — a  neurologist — told  her  she  had  a  floating  kidney, 
and  he  barely  mentioned  it,  remarking  that  it  might 
trouble  her  some  time.  She  said  she  had  had  many  elabo- 
rate examinations  of  her  chest,  blood  tests,  tuberculin 
tests,  and  urine  and  sputum  analyses,  but  no  one  even 
suspected  the  kidney  and  colon.  She  had  been  treated 
by  these  physicians  for  neurasthenia  and  intestinal  in- 
digestion. 

The  foregoing  is  a  common  and,  from  my  point  of  view, 
a  rather  discreditable  picture.  The  diagnostic  ohsessive 
apatliji  that  exists  among  the  rank  and  file  of  the  profes- 
sion regarding  the  pathology  in  question  is  almost  be 
yond  belief  or  explanation.  I  believe  the  tendency  to 
neglect  this  serious  pathologic  condition  is  simply  a  bit 
of  every-day  human  nature,  arising  from  disinclination  to 
delve  into  that  which  is  not  definitely  understood  and  for 
which,  if  discovered,  one  is  unable  to  apply  a  satisfactory 
remedy. 


rOREWORD.  11 

What  it  is  hoped  to  accomplish  by  here  recording  my 
observations  and  experience  is  to  furnish  a  remedy  for 
this  unsatisfactory  state  of  affairs.  If  by  the  use  of  some 
original  theories,  and  others  equally  as  good,  an  etiology 
can  be  formulated  that  is  not  only  simple  to  understand 
and  reasonable  in  theory,  but  which  is  also  based  on 
sound  mechanical  principles,  a  comprehensive  symptoma- 
tology advanced,  a  method  of  diagnosis  described  that 
every  general  practitioner  can  apply,  and  a  plan  of  treat- 
ment recommended  that  will  give  positive  results  in  the 
relief  of  symptoms,  then  my  object  will  be  attained  and 
the  science  of  this  important  field  of  endeavor  be  ad- 
vanced. 

The  prevalence  of  nephrocoloptosis  is  widespread  and 
not  wholly  confined  to  any  class,  nationality,  age,  or  sex. 
The  floating  kidney  is  found  among  the  Bedouin  women, 
who  live  a  nomadic  life  close  to  nature,  where  the  de- 
velopmental restraints  of  civilization  and  the  corset  play 
no  part,  as  well  as  among  the  women  of  the  most  civilized 
countries,  where  dress  and  artificial  ways  of  living  are  so 
much  in.  evidence.  The  hard-working,  muscular  factory 
girl  and  the  delicate,  pampered  society  belle  suffer  equal- 
ly. Many  cases  of  nephroptosis  have  been  noted  in 
young  children,  and  I  have  seen  a  well-marked  case  in  a 
girl  of  8  years  of  age. 

Women  are  much  more  subject  to  the  displacement 
than  men,  and  yet  many  cases  among  men  have  been 
noted  by  other  observers.  Suckling^  states  that  he  has 
found  movable  kidney  present  in  about  forty  percent  of 
women  and  in  six  to  seven  percent  of  men  suffering  from 
nervous  disorders. 

As  my  work  has  been  almost  entirely  confined  to  the 
gynecologic  field,  my  observations  relate  largely  to  ex- 

1  Movable  Kidney,   1909. 


12  FOKEWORD. 

perience  in  connection  with  the  diseases  of  women.  Of 
the  last  two  hundred  examinations  of  women  presenting 
themselves  with  histories  of  some  kind  of  abdominal  or 
pelvic  disease,  I  have  found  floating  kidneys  present  in 
fifty-six— fifty-one  right  nephroptoses  and  five  in  which 
both  kidneys  were  down,  but  not  one  case  of  only  a  left 
displacement.  In  four  hundred  cases  preceding  this  se- 
ries I  found  seventy-six  floating  kidneys — seventy-four  on 
the  right  side  and  two  on  both  sides — but  here,  also,  not 
one  only  on  the  left  side.  In  another  series  of  four  hun- 
dred cases  preceding  the  second  series  I  reioort  only 
twenty-three  cases — nineteen  on  the  right  side  and  four 
on  both  sides.  These  three  series  show  percentages  of 
28,  19,  and  5.75  respectively.  The  larger  percentage  in 
the  more  recent  series  doubtless  represents  the  difference 
in  skill  acquired  in  their  diagnosis,  as  well,  jjrobably,  as 
my  increasing  interest  in  looking  for  them. 

A  comprehensive  understanding  of  the  subject  should 
lead  to  more  thorough  diagnostic  effort  directed  to  the 
kidney  and  colon  than  is  usually  displayed  in  the  public 
institutions  conducted  for  the  treatment  of  those  suffer- 
ing from  nervous  and  mental  disorders.  I  have  been  of 
the  opinion  for  a  long  time  that  our  asylums  and  sani- 
toriums  have  many  chrouic  invalids  whose  mental  re- 
cuperation could  be  assisted  b}^  the  discovery  and  treat- 
ment of  this  condition.  Many  may  also  be  saved  from 
complete  mental  breakdown  by  the  early  recognition  of 
the  condition,  as  the  long  continued  malnutrition,  intes- 
tinal irritation,  toxemia,  and  neurasthenia  caused  by  the 
displacement  are  so  frequently  the  chief  factors  in  the 
beginning.  The  young  woman  who  has  a  sudden  nervous 
collapse,  preceded  for  some  time  by  indigestion,  flatu- 
lence, headaches,  insomnia,  progressive  emaciation,  and 
anemia,  may  be  sufl'ering  from  nephrocoloptosis,  and  not 


FOEEWORD.  13 

be  one  of  those  common  cases  where  the  easy  diagnosis  of 
' '  just  nerves ' '  is  made. 

Suckling  refers  to  nephroptosis  as  a  frequent  and  most 
positive  cause  in  mental  and  nervous  disorders  in  the  fol- 
lowing words:  *'A11  |)hases  of  mental  disturbance  are 
met  with  in  dropped  kidney,  but  mental  depression  and 
melancholia  are  the  most  frequent.  The  following  con- 
ditions are  very  common:  loss  of  memory,  suicidal  tend- 
encies, mental  confusion,  homicidal  impulses,  mental  de- 
pression, morbid  fears,  melancholia,  emotional  disturb- 
ances. The  frequency  of  suicide  when  dropped  kidney 
exists  is  remarkable."  An  operation  for  this  condition 
made  by  myself  in  an  asylum  had  a  most  happy  outcome 
— the  patient,  a  young  woman  of  fine  education  and  bril- 
liant literary  attainments,  recovering  and  afterwards 
inarrying.  A  photograph  of  her  first  baby — a  fine, 
healthy  boy — was  sent  me  four  3^ears  after  the  operation. 

I  am  under  obligations  to  the  following  persons  for 
valuable  assistance  in  the  prej)aration  of  the  material  for 
this  book:  Norman  Saxon  Chamberlin,  the  artist  who 
made  all  the  drawings  and  also  contributed  many  helpful 
suggestions;  Dr.  C.  B.  Burr,  who  contributed  the  article 
on  "Psychiatric  Nephroenteroptic  Symptomatology," 
and  rendered  valuable  revisionary  assistance;  Dr.  P.  M. 
Hickey,  who  contributed  the  article  on  the  "Technic 
of  the  Examination  of  the  Gastro-intestinal  Tract  by 
Means  of  the  Rontgen  Ray, ' '  made  all  of  the  radiographs, 
and  gave  freely  of  time  and  energy  in  their  preparation; 
Dr.  William  E.  Blodgett,  who  contributed  the  article  on 
"Orthoioedic  Considerations  of  Abdominal  Ptosis;"  and 
the  publishers,  who  have  been  most  generous  and  pains- 
taking in  practical  co-operation. 


CONTENTS. 


CHAPTER  I. 

Anatomy  akd  Pathology. 

PAGE 

The  nephrocolic  ligament — Diagrammatic  description  of  the  rela- 
tions of  the  kidneys  with  other  organs  and  tissues  involved  in 
nephrocoloptosis — The  kidneys  and  their  capsules — Importance 
of  the  fatty  capsule  in  the  formation  of  the  nephrocolic  liga- 
ment— Directions  for  the  dissection  necessary  to  demonstrate 
the  presence  of  the  nephrocolic  ligament — Gerota's  capsule — 
Large   intestine — Duodenum — Common  hile  duet — Stomach     .       21 

CHAPTER  II. 

Etiology. 

Hereditary  weakness  of  restraining  tissues  the  primary  cause  of 
ptosis  of  internal  organs — Contributing  or  secondary  causes — 
The  union  of  colon  with  kidney  by  the  nephrocolic  ligament, 
causing  the  kidney  to  be  pulled  oiit  of  place  by  the  prolapsed 
colon,  the  principal  contributory  etiologic  factor — Combination 
of  conditions  necessary  to  the  displacement  of  the  kidney — 
Lack  of  restraining  power  of  the  hepatocolic  ligament  causes 
the  commencement  of  the  chain  of  pathology  which  later  in- 
volves the  kidney — Explanation  of  great  predominance  of  right 
nephroptosis  is  in  the  action  of  the  nephrocolic  ligament — Long, 
loose  nephrocolic  ligament  allows  coloptosis  without  nephropto- 
sis— Faulty  body  shape  only  one  of  the  contributory  causes     .       48 

CHAPTER  III.         ,^ 

Symptomatology, 

Symptoms  complex  and  varied  resulting  in  liability  of  erroneous 
diagnoses — Intestinal  manifestations  usually  the  most  predomi- 
nant— Distended  cecal  end  of  the  colon  often  causes  symptoms 
simulating  appendicitis — Colonic  angulations  the  cause  of  much 
abdominal  pain,  and  even  stoppage — Constipation  or  diarrhea, 
with  mucous  stools,  very  generally  present — Toxemia  frequently 
caused  by  a  colonic  stasis — Nervous  manifestations  of  all  de- 
grees of  severity,  commonly  met  with,  often  of  a  melancholic 
character — "Nervous  breakdown"  in  the  young — Psychopathic 
nephroenteroptic  symptomatology,  by  C.  B.  Burr,  M.  D.— Dietl's 
crisis  causes  symptoms  simulating  peritonitis — Jaundice  and 
"biliousness"  caused  by  traction  on  the  duodenum     ....       53 

15 


16  CONTENTS. 


CHAPTER  IV. 

Diagnosis. 

PAGE 

Drudgery  of  painstaking  examination  can  not  be  avoided — History 
one  of  long  standing-^Dyspepsia  and  neurasttienia — Facial  ex- 
pression in  chronic  cases — Chronic  diarrhea,  or  alternating 
diarrhea  and  constipation — Pain  and  tenderness  at  McBurney's 
point — Diagnosis  of  coloptosis  always  certain  in  cases  of  neph- 
roptosis— Physical  examination  essential  in  all  cases — Posture 
very  important — Dorsal  and  lateral  decubitus — Inflation  of 
stomach  and  bowel  when  radiograph  is  impracticable — Radio- 
graph the  most  important  aid  to  diagnosis — Technic  of  the  ex- 
amination of  the  gastro-intestinal  tract  by  means  of  the  Ront- 
gen  ray,  by  Preston  M.  Hickey,  M.  D. — Differential  diagnosis       64 


CHAPTER  V. 

Teeatment. 

Treatment  must  be,  to  a  large  extent,  mechanical — The  complex 
pathology  must  be  recognized  in  the  treatment — Prophylactic: 
In  the  young;  Orthopedic  considerations,  by  Wm.  E.  Blodgett, 
M.  D.;  Early  attention  to  the  colonic  function;  Supervision  of 
the  family  physician  in  cases  of  underdeveloped  children  of 
importance — Medicinal:  Directed  principally  to  the  colonic 
function;  Cathartics  to  be  avoided;  Oil  and  other  "lubricants" 
recommended;  Physostigmin  in  Dietl's  crisis — Topical:  Heat 
the  most  important  agent — Mechanical:  Kidney  must  be  sup- 
ported, indirectly,  by  supporting  the  colon;  Bands,  supports, 
corsets,  and  trusses;  Adhesive  plaster  band;  Author's  abdomi- 
nal supporter — Operative:  Result  of  stripping  away  fatty  cap- 
sule in  the  customary  operation  of  nephropexy  is  increased 
colonic  ptosis;  Author's  operation  of  nephrocolopexy  fixes  both 
kidney  and  bowel  by  utilizing  the  nephrocolic  ligament;  Tech- 
nic of  author's  operation;  Post-operative  considerations     .      .       79 


CHAPTER  VI. 

Reports  of  Cases. 

Operation  of  nephrocolopexy  in  fifty-four  cases — Details  of  diagno- 
sis— Radiographs  in  many  cases — Additional  operations  not 
contraindicated — Tabulated  resume,  showing  essential  results^ — 
Most  remarkable  in  restoring  the  colonic  function  and  normal 
nutrition — No  mortality — Convalescence  comparatively  painless 
and  comfortable — Nonoperative  cases,  illustrating  various  in- 
teresting phases  of  obscure  symptomatology  and  the  great  as- 
sistance  of   the   radiograph    in  diagnosis 130 


ILLUSTRATIONS. 


Ligamentum  Nephrocolicum — (Longyear) Frontispiece 

PAGE 

Figs.  1,  2.     Diagrams  illustrating  the  relation's  of  the  kidney  with  the 

other  organs   and  tissues   involved   in  nephrocoloptosis     .      .       23,  24 

Fig.  3.     Front  view — Schematic  drawing  showing  the  normal  location 

of  the  organs  involved  in  the  pathology  of  nephrocoloptosis    .      .       26 

Fig.  4.     Front  view — Schematic  drawing  showing  the  resultant  chain 

of  pathology  following  prolapse  of  the  colon  at  the  hepatic  flexure     27 

Fig.  5.  Back  view — Schematic  drawing  showing  the  situation  of  the 
nephrocolic  ligament  and  the  normal  location  of  the  organs  in- 
volved in  the  pathology  of  nephrocoloptosis 30 

Fig.  6.  Back  view — Schematic  drawing  showing  the  etiologic  im- 
portance of  the  nephrocolic  ligament  and  the  resultant  chain  of 
pathology  following  the  prolapse  of  the  colon  at  the  hepatic  flexure     31 

Fig.  7.  Location  of  the  incision  in  the  cadaver  for  the  removal  of  the 
attached  kidney  and  colon  in  the  demonstration  of  the  presence 
of    the    nephrocolic    ligament 33 

Fig.  8.  Method  of  dissection  for  the  removal  of  the  attached  kidney 
and  colon  for  the  demonstration  of  the  presence  of  the  nephrocolic 
ligament 34 

Fig.  9.     Posterior  view  of  the  right  kidney,  colon,  and  cecum,  showing 

the    nephrocolic    ligament 35 

Fig.  10.     Anterior     (peritoneal)     view — The     nephrocolic     ligament — 

Right  kidney,  cecum,  and  colon 36 

Fig.    11.     Anterior     (peritoneal)     view — The    nephrocolic    ligament — 

Right  kidney,  cecum,  and  colon 37 

Fig.  12.  Anterior  (peritoneal)  view — ^The  nephrocolic  ligament — ( 
Left  kidney — Attached  portion  of  colon 38 

Fig.  13.     Transverse  section  showing  the  relations  of  Gerota's  capsule 

and   the   nephrocolic    ligament 40 

Fig.   14.     Technic   of  physical    examination    for   nephroptosis — Dorsal 

decubitus — First  position  of  examiner's  hands 66 

Fig.    15.     Technic   of  physical   examination   for    nephroptosis — Dorsal 

decubitus — Second  position  of  examiner's  hands 67 

Fig.   16.     Technic  of  physical  examination   for   nephroptosis- — Lateral 

decubitus — First  position  of  examiner's  hands 68 

Fig.  17.     Technic   of  physical   examination  for  nephroptosis — Lateral 

decubitus — Second   position   of  examiner's  hands 69 

Fig.  18.  Technic  of  physical  examination  for  nephroptosis — First  po- 
sition of  examiner's  hands  in  both  positions  of  the  patient     .      .       70 

Fig.   19.     Technic  of  physical   examination   for   nephroptosis — Second 

position  of  examiner's  hands  in  both  positions  of  the  patient  .      .       71 

17 


18  ILLUSTRATIONS. 

PAGE 

Fig.  20.     Faulty    standing    posture 82 

Fig.  21.     Favorable    standing   posture 82 

Fig.  22.     Faulty  sitting  posture 83 

Fig.  23.     Favorable  sitting  posture 83 

Fig.  24.     Author's    abdominal    supporter 95 

Fig.  25.     Position  assumed  while  massaging  the  abdomen  previous  to 

fastening  the  truss  attachment  of  the  author's  abdominal  suppoi'ter       96 
Fig.   26.     Front  view — Proper  adjustment  of  the  author's   abdominal 

supporter 9'i^ 

Fig.    27.     Side   view — Proper    adjustment    of    the    author's    abdominal 

supporter 98 

Fig.    28.     Back   view — The   result   of  cutting   away   the  fatty   capsule 

from  the  kidney  in  the  old  operation  of  nephropexy     ....     100 
Fig.  29.     Author's  kidney  elevator  used   in  the  operation  of   nephro- 

colopexy 103 

Fig.  30.     Method   of  using  the  author's  kidney  elevator     ....     105 
Fig.  31.     Instruments  used  by  the  author  in  the  operation  of  nephro- 

colopexy 1**'"' 

Fig.  32.     The    operation    of    nephrocolopexy — ^Method    of    finding    the 

nephrocolic  ligament  after  Gerota's  capsule  is  entered     .      .      .     108 

Fig.  33.     Skeleton    reference    to    Fig.    32 109 

Fig.  34.  The  operation  of  nephrocolopexy — Fasciculi  of  the  nephro- 
colic   ligament    drawn    out 112 

Fig.    35.     Skeleton    reference    to    Fig.    34 113 

Fig.  36.  The  operation  of  nephrocolopexy — ^Method  of  gathering  to- 
gether the  entire  nephrocolic  ligament  by  the  use  of  the  forceps- 
hook       114 

Fig.  37.     Skeleton    reference    to    Fig.    36 115 

Fig.  38.     The  operation  of  nephrocolopexy — Method  of  forming  a  loop 

of  the  nephrocolic  ligament  by  opening  the  forceps-hook     .      .      .     116 

Fig.  39.     Skeleton    reference    to    Fig.    38 117 

Fig.  40.     Front  view — The  operation  of  nephrocolopexy — The  scheme 

of  operation 118 

Fig.  41.     Skeleton    reference   to    Fig.    40 119 

Fig.  42.     Front  view — The    operation    of    nephrocolopexy — Closure    of 

the   transversalis    fascia 120 

Fig.  43.     Skeleton    reference    to    Fig.    42 121 

Fig.  44.     Front  view — The  operation  of  nephrocolopexy — Final  closure 

of    the    wound 122 

Fig.  45.     Skeleton    reference    to    Fig.    44 123 

Fig.  46.     The  operation  of  nephrocolopexy — Completed  operation     .      .     124 

Fig.  47.     Skeleton    reference   to    Fig.    46 125 

Fig.  48.  Position  of  kidney  before  and  after  fixation  of  the  nephro- 
colic   ligament 126 

Fig.  49.  Method  of  applying  post-operative  abdominal  pad  in  the  op- 
eration   of    nephrocolopexy 127 


ILLUSTEATIONS.  19 

PAGE 

Figs.  50  to  69.  Radiographs  of  colonic  and  gastric  displacements  ac- 
companying reports   of  operative   cases 151-211 

Figs.  70  to  86.  Radiographs  of  colonic  and  gastric  displacements  ac- 
companying reports  of  nonoperative  cases 221-238 

Fig.  87.  Radiograph  showing  complete  coloptosls  following  old  opera- 
tion of  nephropexy 240 

Fig.  88.     Radiograph    showing   displaced    colon    raised    by    recumbent 

position 241 


NEPHEOCOLOPTOSIS. 


CHAPTER  I. 
ANATOMY  AND  PATHOLOGY. 

In  the  presentation  of  the  subject  of  the  anatomy  of 
the  parts  involved  in  the  pathology  in  question,  no  new 
or  previously  unrecognized  tissue  is  offered  for  considera- 
tion, but,  instead,  the  privilege  is  claimed  of  presenting 
a  new  name  and  a  newly  discovered  function  for  a  previ- 
ously recognized  anatomical  part,  whose  important  office 
had  not  been  recognized  until  it  was  presented  by  the 
author  to  the  profession  in  an  original  observation  re- 
ported first  in  the  transactions  of  the  Michigan  State 
Medical  Society,  in  June,  1905,^  and  three  months  later 
in  a  presidential  address  before  the  American  Association 
of  Obstetricians  and  Gynecologists. - 

Apart  from  the  description  of  the  nephrocolic  ligament, 
the  anatomical  descriptions  in  this  book  are  drawn  from 
well-known  sources.  Only  those  parts  which  are  pri- 
marily concerned  in  the  displaced  colon  and  kidney,  and 
those  which  are  secondarily  affected  as  a  result  of  the 
displacement,  will  be  considered.  The  prime  object  is 
to  direct  attention  to  the  essentials  which  have  an  im- 
mediate mechanical  bearing  on  the  parts  involved. 

While  the  apparatus  under  consideration  has  that  vital 
force  which  is  called  "life"  or  "vitality,"  and  which 


iJournnl  Michigan  Stale  Medical  Society,  vol.   5,  No.  1,  p.   41. 

=  "A  Study  of  Floating-  Kidney,  witli  Sug-g-estions  Changing  the  Opera- 
tive Technic  of  Nephropexy,"  Transactions  American  Association  Obstetri- 
cians and  Gynecologists,  1906. 

21 


22  N^EPHKOCOLOPTOSIS. 

must  be  accounted  an  important  factor  in  any  study  of 
the  various  parts  concerned  in  the  displacements,  this 
condition  is  almost  purely  of  a  mechanical  nature,  and 
may  very  properly,  and  it  is  thought  with  profit,  be 
treated  largely  from  a  mechanical  standpoint. 

The  parts  to  be  described  are  arranged  diagrammatic- 
ally  for  the  purpose  of  iudicating  the  relations  of  the  dis- 
placed organs  to  each  other,  and,  as  far  as  possible,  also 
the  continuity  of  the  various  structures  with  each  other, 
which  continuity  makes  possible  the  ptoses  and  their 
sequelae.  It  will  be  found  that  this  arrangement  also 
simplifies  the  question  of  pathological  sequence  of  in- 
volvement of  the  various  organs. 

Relations  of  the  Kidneys  with  Other  Organs  and  Tissues. 

The  following  two  illustrations  are  diagrams  showing 
the  relations  of  the  kidneys  with  the  other  organs  and 
tissues  involved  in  nephrocoloptosis. 

By  referring  to  and  comparing  the  two  diagrams,  a 
glance  is  sufficient  to  impress  the  mind  with  the  fact  that 
the  right  kidney,  because  of  its  adhesion  to  and  intimate 
relations  with  more  important  tissues  than  is  the  left, 
must  be  of  the  greater  relative  importance  in  any  con- 
sideration of  the  displacement  of  the  two  organs.  It  is 
especially  interesting  to  note  the  relations  of  the  right 
kidney  to  the  organs  above  it  which  become  influenced  by 
the  nephroptosis.  The  chain  of  descensus  is  thus  seen 
as  beginning  from  below,  with  the  hepatocolic  ligament 
relaxation  (or  absence);  then,  in  succession,  the  right 
end  of  the  colon,  then  through  the  nephrocolic  ligament, 
the  kidney  (which  degree  of  displacement  may  be  influ- 
enced by  the  adhesion  to  Gerota's  capsule),  duodenum 
(by  its  adhesion  to  the  fatty  capsule,  and  held  in  angula- 
tion by  the  mesocolon),  stomach,  common  bile  duct — the 


ANATOMY  AND    PATHOLOGY. 


23 


latter  disturbing  the  function  of  the  liver  and  pancreas. 
On  the  other  hand,  the  left  kidney,  being  isolated,  as  it 
were,  above  (the  duodenal  adhesion  so  slight  as  to  be 


Liver,  pancreas  j 

Mesocolon 

Ck)m.  bile  duct 

1       Stomach        | 

1     1 

Duodenum 

Gerota's  capsule 


Nephrocolic  ligament 


Cecum,  ascending  and  transverse  colon 


Hepatocolic  ligament 


Fig-.  1.  Diagram  showing-  the  right  kidney;  the  fatty  capsule  sur- 
rounding it,  and  passing  downward  to  form  the  nephrocolic  ligament; 
Gerota's  capsule  to  the  outside  of  and  attached  to  the  fatty  capsule,  and 
passing  downward  to  form  part  of  the  nephrocolic  ligament;  the  ascend- 
ing colon  connected  with  the  kidney  through  the  nephrocolic  ligament; 
the  hepatocolic  ligament  attached  to  the  colon.  Above  the  kidney  the 
duodenum  adherent  to  the  fatty  capsule;  stomach  connected  with  and 
continuous  with  the  duodenum;  common  bile  duct  connected  with  the 
duodenum,  and  liver  and  pancreas  with  it;  mesocolon,  where  duodenum 
passes  under  it. 


negligible),  its  displacement  affects  no  other  important 
organs.  The  great  complexity  of  symptoms  arising  from 
a  right  nephroptosis,  and  the  rarity  of  symptoms  of  a  left 
side  displacement — which  must  be  of  a  renal  character 
exclusively — are  thus  clearly  indicated. 


24 


NEPHROCOLOPTOSIS. 


The  kidney,  being  the  center  of  disturbance,  will  be  de- 
scribed in  detail  first,  and  then  the  other  organs  accord- 
ing to  their  etiologic  importance  in  the  displacement. 


Gerota's  capsule 


Nephrocolic  ligament 


Transverse  and  descending  colon 


Phrenoeolic  ligament 


Fig.  2.  Diagram  showing-  tlie  left  kidney;  the  fatty  capsule  surround- 
ing it,  and  passing  downward  to  form  the  nephrocolic  ligament;  Gerota's 
capsule  to  the  outside  of  and  attached  to  tlie  fatty  capsule,  and  passing 
downward  to  form  part  of  the  nephrocolic  ligament;  tlie  colon  connected 
witli  tlie  kidney  through  the  nephrocolic  ligament;  the  phrenoeolic  liga- 
ment attached  to  the  colon. 

The  Kidneys. 

The  kidneys  are  bean-shaped  organs,  situated  on  either 
side  of  the  spinal  column.  (Fig,  3,  Nos.  4,  9.)  They  are 
usually  described  as  lying  in  the  lumbar  region,  but  are 
really  intersected  by  the  horizontal  and  vertical  planes 
which  separate  the  hypochondriac,  lumbar,  epigastric, 
and  umbilical  regions  from  each  other,  and  may  therefore 
be  said  to  pertain  to  all  three  segments  of  the  abdominal 
space.  They  lie  on  the  fascia  of  the  quadratus  lumborum 
muscle  and  on  the  vertebral  portion  of  the  diaphragm, 
and  extend  from  about  the  third  lumbar  vertebra  to  the 
eleventh  rib,  or  even  above.  The  left  kidney  is  somewhat 
higher  than  the  right.     They  are  usually  of  a  flattened 


ANATOMY  AND    PATHOLOGY.  25 

oval  shape,  with  the  long  diameter  nearly  parallel  to  the 
vertebral  column;  but  the  form  is  variable,  and  they  may 
be  slender,  the  length  being  three  times  the  breadth,  and 
the  convex  and  concave  borders  almost  concentrically 
curved;  or  they  may  be  short  and  broad,  the  vertical 
diameter  being  only  a  little  greater  than  the  transverse. 
The  '^ horse-shoe"  kidney  is  found  quite  frequently,  and 
other  anomalous  forms  may  be  encountered. 

Each  kidney  is  about  four  inches  in  length,  two  inches 
in  breadth,  and  about  one  inch  in  thickness,  the  left  being 
somewhat  longer  and  thinner  than  the  right.  The 
weight  of  the  organ  in  the  adult  varies  from  four  to  six 
ounces,  being  somewhat  heavier  in  the  male  than  in  the 
female,  and  the  left  kidney  slightly  heavier  than  the 
right. 

The  kidney  is  surrounded  by  two  sheaths — an  inner 
fibrous  layer  called  the  true  capsule,  and  an  outer  so- 
called  fatty  sheath  or  capsule.  As  it  is  in  the  latter — the 
fatty  capsule — that  our  special  interest  lies,  being  the 
tissue  the  framework  of  which  forms  the  nephrocolic 
ligament,  it  will  be  of  interest  to  note  the  observations  of 
others  on  this  particular  structure. 

Gray:  An  old  edition  of  Gray  refers  to  the  fatty  cap- 
sule as  a  "considerable  quantity  of  fat,"  by  which  the 
kidneys  are  usually  surrounded. 

Kelly-Noble:  "The  fatty  capsule  is  developed  espe- 
cially on  the  posterior  aspect  of  the  kidney,  al:)out  the  con- 
vex border  and  the  lower  pole;  in  front  it  is  very  thin. 
•  Beneath  the  inferior  extremity  of  the  kidney  it  forms 
quite  a  pad  or  bolster  for  the  organ,  and  is  continuous 
with  the  cellulo-fatty  tissue  of  the  false  pelvis.  The 
fatty  capsule  itself  is  confined  between  the  two  layers  of 
what  is  known  as  the  perinephric  fascia,  and  throughout 
its  extent  there  are  fibrous  septa  which  pass  from  the 
kidney  to  those  layers. ' ' 


26 


NEPHROCOLOPTOSIS. 


Pig.   3.     Front  view.     Showing-  the  normal   location   of   the  organs   in- 
volved  in   the   pathology   of  nephrocoloptosis. 


1.  Gall-bladder. 

2.  Common  bile  duct. 

3.  Duodenum  at  the  point  of 
attachment  of  the  hepatoduodenal 
ligament  and  where  it  passes  under 
the  gastrocolic  omentum. 

4.  Right  kidney  covered  with 
fatty  capsule. 

5.  Hepatic  flexure  of  the  colon. 

6.  Right  ureter. 


7.      Ileum. 
S.     Cecum. 

9.  Left  kidney  covered  with 
fattj-  capsule. 

10.  Splenic  flexure  of  colon. 

11.  Jejunum. 

12.  Left   ureter. 

13.  Suspensory  muscle  (seen 
through  stomach)  which  supports 
the  duodenojejunal  angle. 


ANATOMY   AND   PATHOLOGY. 


27 


l^-mMneRJirjJ- 


Fig.  4.  Front  view.  Showing- 
lowing  prolapse  of  the  colon  at  the 

1.  Common  bile  duct. 

2.  Gall-bladder. 

3.  Angulation  of  duodenum  at 
the  insertion  of  the  hepatoduodenal 
ligament  and  where  it  passes  under 
the  gastrocolic  omentum. 

4.  Angulation  of  duodenum  at 
point  of  insertion  of  suspensory 
muscle,  behind  stomach. 

5.  Angulation  of  common  bile 
duct. 

6.  Acute  angulation  and  re- 
sultant dilatation  at  splenic  flexure 
of  colon. 

7.  Jejunum. 

8.  Umbilical  region. 


the   resultant   chain    of   pathology    fol- 
hepatic  flexure. 

9.  Right  kidney  displaced  be- 
low costal  margin. 

10.  Angulation  of  duodenum 
at  its  point  of  adhesion  to  the 
fatty  capsule. 

11.  Angulation  of  prolapsed 
transverse  colon  at  its  lowest  point. 

12.  Right  ureter  compressed 
and  kinked. 

13.  Ileum. 

14.  Cecum. 

15.  Appendix  vermiformis  sit- 
uated low  in  pelvis. 

16.  Left  kidney. 

17.  Nephrocolic  ligament  pass- 
ing from  right  kidney  to  posterior 
wall  of  descending  colon. 


28  NEPHROCOLOPTOSIS. 

Will.  Billiiigton,  M.  B.,  M.  S.,  Lond.,  F.  R.  C,  S.,  in 
''Movable  Kidney  from  a  Surgical  Standpoint:"  "A 
typical  movable  kidney,  as  seen  dnring  oxoeration,  pre- 
sents certain  well-marked  features.  The  true  capsule  is 
thickened  and  has  a  mottled  appearance,  due  to  the  pres- 
ence of  opaque,  yellowish-white  patches  of  varying  size. 
These  patches  indicate  areas  of  greater  thickness,  and  to 
them  are  attached  adhesions,  often  of  great  strength. 
The  perirenal  fat  is  usually  scanty,  and  its  place  is  taken 
by  adhesions  which  surround  the  entire  kidney.  The  ad- 
hesions are  sheet-like  in  appearance,  with  dense  bands 
leading  to  the  opaque  patches  on  the  true  capsule.  They 
extend  between  the  true  capsule  and  the  fascial  capsule 
outside.  .  .  .  Sometimes  the  adhesions  hetiveen  the  colon 
and  kidney  are  very  dense  and  their  separation  is  effected 
with  difficttlty .'' ^    (Italics  by  the  author.) 

C.  A.  L.  Reed,  of  Cincinnati,  in  "A  New  Technique  for 
the  Fixation  of  Floating  Kidney,  with  Special  Reference 
to  the  Utilization  of  Long-year's  Ligament:"  .  .  . 
' '  But  another  thing  that  impressed  me  was  the  frequency 
with  which,  in  endeavoring  to  enucleate  the  kidney,  I 
found  it  bound  down  by  apparently  connective  tissue, 
striae  extending  downward  from  its  lower  extremity.  I 
took  the  trouble  to  see  if  these  striae  belonged  there,  but 
found  no  reference  to  them,  either  in  the  anatomies  or  in 
Glautenay  and  Gerota's  valuable  contribution  on  "Le 
Fascia  Perirenal." 

Zuckerkandl  was  equally  silent?  ' '  I  accordingly  looked 
upon  the  structure  as  strictly  adventitious,  probably  of 
inflammatory  origin;  but,  as  it  seemed  to  hold  the  kidney 
in  its  displaced  position,  I  divided  it  with  scissors.  This 
left  a  good  stump,  which,  situated  as  it  was,  seemed  to  be 
a  good  thing  to  stitch  into  the  upper  angle  of  the  wound, 
where  it  served  a  good  purpose  in  holding  the  kidney  pre- 


ANATOMY   AND    PATHOLOGY.  29 

cisely  where  it  belonged.  .  .  .  The  lower  segment  of 
the  ligament  is  best  disposed  of  by  fixation  to  the  lower 
margin  of  the  wound. ' ' 

Thus  is  seen  the  development  of  recognition  of  the  fact 
that  the  structure  of  the  fatty  capsule  is  something  be- 
sides fat  and  loose  connective  tissue.  The  last  two 
observers — surgeons  of  large  experience — are  emphatic 
in  their  opinion  regarding  the  strength  of  the  tissue. 
Both  believed  its  volume  and  strength  to  be  of  inflamma- 
tory origin,  and  thus  abnormal  and  adventitious.  Bil- 
lington's  observation  that  this  condition  is  peculiar  to 
cases  of  nephroptosis  coincides  with  that  of  the  author, 
and  seems  to  cover  a  valuable  point  in  the  anatomic  ex- 
perience of  some  others,  who,  failing  to  find  the  ligament 
as  described,  base  their  opinions  on  the  examination  of 
subjects  which  have  had  no  displacement  of  the  kidney. 

If  Billington  and  Eeed  had  gone  a  little  farther  and 
examined  the  attachment  of  this  tissue,  they  would  have 
found  the  distal  portion  in  the  posterior  wall  of  the  colon, 
and  that  the  bowel  formed  the  resistance  which  pre- 
vented the  easy  delivery  of  the  kidney,  which  was  liber- 
ated by  cutting  through  the  tissue,  as  reported  by  Reed. 
This  is  as  the  author  finds  it,  and  would  define  the  struc- 
ture as  follows: 

The  Fatty  Capsule. 

The  fatty  capsule  is  a  sheath  which  envelops  the  whole 
kidney,  is  situated  upon  and  attached  to  the  surface  of  the 
fibrous  capsule,  and  is  composed  of  a  network  of  fine 
fasciculi,  or  tendonse,  interspersed  more  or  less  with  fat. 
The  fasciculi  composing  the  network  of  the  capsule  coa- 
lesce at  the  lower  pole  of  the  kidney,  and,  passing  longi- 
tudinally downward,  form 


30 


NEPHROCOLOPTOSIS. 


Fig.  5.  Back  view.  Sliowing  tli 
ment  and  the  noi-mal  location  of  tlie 
nephrocoloptosis. 

1.  Gall-bladder. 

2.  Duodenojejunal  angle  at  the 
point  of  Insertion  of  the  suspen- 
sory muscle. 

3.  Right  kidney  covered  with 
fatty  capsule,  and  duodenum  ad- 
herent to  front  surface  of  capsule. 

4.  Right  ureter. 

5.  Jejunum. 


e    situation    of   the    nephrocolic   liga- 
organs   involved  in  the  pathology  of 

6.  Right  nephrocolic  ligament 
inserted  in  posterior  wall  of  colon 
between   peritoneal    reflection. 

7.  Umbilical   region. 

8.  Cecum. 

9.  Left  kidney  covered  with 
fatty  capsule. 

10.  Left  nephrocolic  ligament. 


ANATOMY  AND    PATHOLOGY. 


31 


\  -^^;\ 


Fig.  6.  Back  view.  Sliowing  I 
colic  ligament  and  the  resultant  c 
lapse  of  the  colon  at  the  hepatic  fle 

1.  G-all-bladder. 

2.  Common  bile  duct. 

3.  Kink,  or  angle,  in  the  duo- 
denum at  the  insertion  of  the  hep- 
atoduodenal ligament  and  where  it 
passes  over  the  gastrocolic  omen- 
tum. 

4.  Angulation  of  colon  at 
splenic  flexure  caused  by  the  pro- 
lapse of  the  transverse  colon. 

5.  Angulation  of  common  bile 
duct. 

6.  Right  kidney  covered  with 
fatty  capsule. 

7.  Angulation  of  duodenum  at 
its  point  of  adhesion  to  front  sur- 
face of  fatty  capsule. 


le  eLiologic  importance  of  the  nephro- 
hain  of  pathology  following  the  pro- 
xure. 

8.  Right  ureter  compressed  by 
position   of  kidney. 

9.  Right  nephrocolic  ligament 
making  traction  on  kidney  by  pro- 
lapse of  colon  (seen  through 
ileum). 

:  10.     Cecum. 

11.  Left  kidney  covered  with 
fatty  capsule. 

12.  Angulation    at     duodenoje- 
j    junal  junction   at   insertion   of   sus- 
pensory muscle. 

13.  Left  ureter. 

14.  Left  nephrocolic  ligament. 

I  15.     Prolapsed  transverse  colon 

I    and    lines    of    attachment    of    meso- 
,    colon. 


32  NEPHROCOLOPTOSIS. 

The  Nephrocolic  Ligament, 

wMch,  on  the  right  side,  is  inserted  into  the  posterior 
wall  of  the  ascending  colon  between  its  peritoneal  attach- 
ments, and  on  the  opposite  side  in  a  similar  manner  into 
the  descending  colon.  (Fig.  5,  Nos.  3,  6,  9,  10.)  The 
nephrocolic  ligament  is  adherent,  ventrally,  to  the  peri- 
toneum above  its  attachment  to  the  bowel;  its  tissue  co- 
alesces with  the  attenuated  wall  of  the  anterior  lamella  of 
Gerota's  capsule,  which  adds  considerably  to  its  tensile 
strength.  The  "ligament"  is  an  irregularly  shaped 
aggregation  of  fasciculi,  which  have  much  resisting 
power  when  bunched  together,  but  it  may  be  readily  torn 
apart  and  its  continuity  destroyed  if  carelessly  and 
roughly  handled,  or  if  traction  is  made  upon  it  section- 
ally  with  tearing  or  lacerating  instruments. 

To  demonstrate  the  nephrocolic  ligament  in  its  integ- 
rity, showing  its  relations  and  attachments,  the  following 
directions  for  the  dissection  should  be  observed: 

Lay  open  the  entire  upper  abdominal  cavity  (Fig.  7) 
to  inspection  by  an  incision,  severing  all  of  the  tissues  of 
the  abdominal  wall  superiorly  and  laterally,  beginning  at 
Poupart's  ligament  below  the  crest  of  the  ileum  on  one 
side,  passing  upward  close  to  the  side  as  far  as  the  costal 
margin,  then  across  to  the  opposite  side  and  down  to 
Poupart's  ligament.  The  flap  thus  made  and  turned 
downward  exposes  the  entire  cavity,  so  that  the  ascend- 
ing and  descending  colon,  with  the  hepatic  and  splenic 
flexures,  may  be  readily  reached,  and  their  attachments  to 
the  kidney  demonstrated  without  mutilative  dissection. 

On  the  right  side,  tie  and  cut  loose  the  ileum  close  to  the 
cecum,  and  the  transverse  colon  near  the  hepatic  flexure, 
sever  the  peritoneal  attachments  of  the  ascending  colon 
and  the  peritoneum  covering  the  kidney,  so  as  to  leave 


ANATOMY   AND    PATHOLOGY. 


33 


the  bowel  and  kidney  covered  with  the  membrane.  (Fig. 
8.)  Then  pass  the  hand  under  both  bowel  and  kidney, 
and  dissect  them,  held  thus  together  and  protected  by  the 
hand,  from  the  loose  attachments  to  the  back  and  the 
tougher  tissue  composing  Gerota's  capsule.     The  remain- 


Pig.  7.  Showing-  the  location  of  the  incision  in  tlie  cadaver  for  the 
removal  of  the  attached  kidney  and  colon  in  the  demonstration  of  the 
presence  of  tlie  nephrocolic  ligament. 

ing  attachment  will  be  the  blood  vessels  and  ureter, 
which  may  be  severed  with  the  scissors.  Now,  with  the 
specimen  still  in  hand,  turn  it  over,  with  the  peritoneal 
side  downward,  and  on  removing  the  hand,  which  covers 
the  back  of  the  kidney  and  bowel,  the  connection  of  the 


34 


NEPHROCOLOPTOSIS. 


kidney  to  the  colon  by  the  nephrocolic  ligament  is  readily 
seen.     (Fig.  9.) 

To  demonstrate  the  ligament  still  farther,  turn  the 


Fig.  8.  Showing-  the  method  of  dissection  for  the  removal  of  tlie  at- 
tached kidney  and  colon  for  tlie  demonstration  of  tlie  presence  of  the 
nephrocolic  ligament. 

specimen  over,  so  that  the  peritoneal  covering  of  the 
kidney  and  bowel  will  be  uppermost;  strip  back  about  a 
half  inch  of  the  cut  edge  of  the  peritoneum  from  the 
parietal  side  of  the  kidney  and  bowel,  and  the  margin  of 


ANATOMY  AND   PATHOLOGY. 


35 


Gerota's  capsule  will  be  uncovered   and   seen   to   pass 

downward  and  merge  with  the  ligament.     (Figs.  10,  11.) 

The  left  side  is  removed  in  like  manner  after  severing 


Peritoneum    jg^K    '^j»* 


Hepatic  flexure 
of  colon 


Margin  of 
peritoneum 


Ascending  colon 


Margin  of  peritoneum 


Cecum 


Fig-.  9.     The  Nephrocolic  Iiigrament.     Posterior  view   of   the  right  kid- 
ne5^  colon,  and  cecum,  showing  the  nephrocolic  ligament. 

the  colon  above  and  below  the  kidney,  and  shows  the 
same  formation  of  capsule  and  ligament.     (Fig,  12.) 

For  the  best  demonstration  a  very  thin  subject  should 
be  used,  as  the  presence  of  much  adipose  tissue  may 


36 


NEPHROCOLOPTOSIS. 


obscure  tlie  characteristic  appearance  of  tlie  ligament. 
Like  many  other  structures  of  the  body,  the  nephrocolic 
ligament  will  be  found  to  vary  much  in  size  and  tensile 
strength  in  different  individuals.  Like  the  round  liga- 
ment of  the  uterus,  whose  constant  presence  in  the  in- 


Fig-  lu.  The  Nephrocolic  Iiig-anient.  Anterior  (peritoneal)  view.  (Same 
specimen  as  Fig.  9,  turned  over.)  Rig-lit  kidney,  cecum,  and  ascending 
colon,  showing  the  anterior  surface  covered  witli  peritoneum,  the  edge  of 
which  has  been  turned  back  between  the  kidney  and  bowel,  showing  the 
nephrocolic  ligament  secured  by  the  forceps-hook  (open),  as  in  the  author's 
operation  of  nephrocolopexy. 


guinal  canal  was  for  many  years  a  subject  of  contro- 
versy, in  a  small  percentage  of  cases  it  will  be  found 
very  fragile,  but,  also  like  the  round  ligament,  it  can 
alwaj^s  be  utilized  for  practical  surgical  purposes  if  skill- 
fully handled,  whether  large  or  small. 

There  is  no  doubt,  however,  that  in  well-marked  cases 


ANATOMY  AND   PATHOLOGY. 


37 


of  nephroptosis  the  fibrillfe  composing  this  structure  are 
much  more  voluminous  and  have  more  tensile  strength — 
and  can  thus  be  practically  utilized — than  in  cases  having 
no  renal  displacements.  Whether  this  increase  of  tissue 
over  the  average  is  cause  or  effect  is  not  known.  It  may 
be  due  to  both — a  congenital  strength  of  the  connection 


Fig-.  11.  The  Nephrocolic  Lig-ament.  Anterior  (peritoneal)  view. 
Rlg-ht  kidney,  cecum,  and  ascending-  colon,  sho-wing  the  anterior  surface  of 
bo-wel  and  kidney  covered  with  peritoneum,  the  edge  of  which  (1)  has  been 
stripped  back  from  the  underlying  capsule  of  GeTota,  showing  its  margin 
(2)  to  pass  downward,  and,  becoming  attenuated,  merge  into  the  nephro- 
colic  ligament  (3),  which  is  seen  secured  with  the  forceps-hook  (open),  as 
in  the  author's  operation  of  nephrocolopexy. 


between  bowel  and  kidney  allowing  the  kidney  to  be 
pulled  out  of  place,  and  afterwards  the  constant  activity 
of  the  connected  parts,  due  to  the  great  mobility,  causing 
increased  development  of  the  ligament  connecting  them. 
The  attachment  to  the  bowel  has  been  found  invariably 
present.  In  some  cases  the  ligament  is  short,  and  binds 
the  bowel  closely  to  the  kidney,  while  in  others  it  is  long 


38 


NEPHROCOLOPTOSIS. 


and  loose,  allowing  a  good  deal  of  play  between  the  kid- 
ney and  bowel.  The  latter  condition  is  believed  to  be 
present  in  cases  of  coloptosis  without  nephroptosis. 

The  nephrocolic  ligament  and  fatty  capsule  may,  for 
illustration,  be  compared  to  the  cordage  of  a  balloon — 
the  kidney  the  bag  of  gas,  and  the  ascending  colon  and 
cecum  the  car. 


Fig-.  12.  Tlie  Neplirocolic  Ligament.  Anterior  (peritoneal)  view.  The 
left  kidney  and  attached  portion  of  the  colon  at  the  splenic  flexure,  show- 
ing- the  anterior  surface  covered  with  peritoneum,  the  edge  of  which  (1) 
has  been  stripped  back  from  the  underlying  capsule  of  Gerota,  showing  its 
margin  (2)  to  pass  downward,  and,  becoming  attenuated,  merge  into  the 
nephrocolic  ligament  (3),  which  is  seen  secured  with  the  foi'ceps-hook 
(open),  as  in  the  author's  operation  of  nephrocolopexy. 


Gerota 's  Capsule. 

Gerota 's  capsule,  or  the  perirenal  fascia,  is  a  compara- 
tively new  anatomical  discovery,  no  mention  of  it  being 
found  in  the  older  text  books  on  anatomy.  At  the  time 
the  author  read  his  first  paper  mentioning  Gerota 's  cap- 
sule, a  demonstrator  of  anatomy  in  a  prominent  medical 
college  called  on  him  and  asked  to  be  shown  the  au- 
thority for  it,  stating  he  had  never  seen  it  in  dissection, 
and  knew  of  no  literature  on  the  subject.  At  that  time 
the  only  reference  at  the  author's  command  was  in  the 


ANATOMY  AND   PATHOLOGY.  39 

article  on  the  kidney  in  that  admirable  encyclopedia, 
''The  Eeference  Handbook  of  the  Medical  Sciences," 
which  was  shown  him.  The  drawing  here  presented 
(Fig.  13)  is  an  adaptation  of  one  in  the  article  referred 
to,  and  shows  clearly  the  mode  of  formation  of  the 
capsule. 

As  the  perirenal  fascia  has  much  to  do  with  both  the 
etiology  and  therapeutics  of  nephroptosis,  its  character- 
istics and  relations  should  be  studied  carefully.  As 
described  by  Gerota,  Zuckerkandl,  Glautenay,  and  others, 
it  is  composed  of  the  subperitoneal  fascia,  which  splits 
into  two  lamellae  when  it  reaches  the  line  upon  the  lateral 
aspect  of  the  abdominal  wall  on  either  side  of  the  body, 
from  which  the  parietal  peritoneum  is  reflected,  to 
pass  on  to  and  over  the  ascending  and  descending  colons 
respectively.  At  this  point  the  fascia  divides  into  two 
layers,  one  of  which  passes  over  the  front  and  on  the  back 
of  the  kidney  of  each  side.  The  anterior  layer  (Fig.  13, 
No.  6),  after  crossing  the  kidney  in  front,  is  continued 
and  joins  its  fellow  of  the  opposite  side,  making  a  con- 
tinuous membrane  overlying  the  posterior  part  of  the  ab- 
dominal wall.  From  the  point  at  which  it  separates  from 
the  anterior  lamella,  the  other,  or  posterior,  leaf  of  the 
perirenal  fascia  passes  behind  the  kidney  and  is  con- 
tinued across  the  psoas  muscle,  to  be  inserted  on  the 
lateral  aspect  of  the  bodies  of  the  vertebrae  near  their 
anterior  surface.     (Fig.  13,  No.  12.) 

The  two  lamellae  meet  at  the  upper  end  of  the  kidney 
and  send  fibers  to  the  under  surface  of  the  diaphragm; 
they  also  pass  between  the  upper  pole  of  the  kidney  and 
the  adrenal  body,  sending  fibers  to  both,  thus  loosely  at- 
taching one  to  the  other.  The  connection  is  not  an  inti- 
mate one,  and  on  this  account  the  adrenal  remains  behind 
when  the  kidney  is  removed,  except  when  there  has  been 


40 


NEPHROCOLOPTOSIS. 


Fig.    13.     Transvei'se    section    showing-   the    relations    of   Gei-ota's    cap- 
After  Gerota,   with   supplemental  no- 


sule  and  tlie  neplirocolic  ligament, 
tations.) 

1.     Psoas  muscle. 

Body    of    the    sacrolumbalis 


2. 
muscle. 

3. 
cle. 


Quadratus    lumborum    mus- 


4.  Peritoneum    (dotted   line). 

5.  Kidney. 

6.  Anterior  lamella  of  Gerota's 
capsule  (becoming  attenuated  as  it 
passes  downward  and  merges  with 
the  nephrocolic  ligament). 

7.  Colon. 

8.  Subperitoneal  fascia. 


9.  Proper  point  of  entrance  to 
Gerota's  capsule  in  the  operation  of 
nephrocolopexy  (close  to  quadratus 
lumborum  muscle,  and  just  below 
the  twelfth  rib). 

10.  Improper  point  of  entrance 
in  the  operation  of  neplirocolopexy 
(peritoneal  cavity,  and  not  Gerota's 
capsule,  will  be  entered). 

11.  Nephrocolic  ligament. 

12.  Posterior  lamella  of  Gero- 
ta's capsule. 


ANATOMY  AND   PATHOLOGY.  41 

a  previous  inflammatory  process  whicli  has  produced  ad- 
hesions, binding  them  together.  In  this  way  there  is 
formed  a  sac  which  incloses  the  kidney  and  its  fatty  en- 
velope, and  which  is  closed  above  and  at  its  outer  side, 
but  is  more  or  less  open  below,  and  entirely  so  toward  the 
median  line  of  the  body — a  very  important  anatomical 
point  in  its  relation  to  nephroptosis. 

The  trabeculaB  forming  the  framework  of  the  fatty 
cupsule  are  more  or  less  adherent  to  the  inner  surface  of 
the  perirenal  fascia,  and,  as  they  are  likewise  attached  to 
the  outer  surface  of  the  fibrous  capsule,  the  kidney's 
motility  is  to  a  considerable  extent  dependent  on  this 
peculiar  distribution  of  tissue.  This  adhesion  to  Gerota's 
capsule  and  its  attachment  to  the  back  around  the  hilum 
and  blood  vessels  form  the  kidneys'  only  defense  against 
dislodgment. 

Thus  it  is  seen  that  the  kidney  is,  first,  surrounded  by  a 
closely  adhering  membrane — the  fibrous  capsule — which 
encases  it  firmly  and  moves  with  it;  second,  around  this 
is  the  fatty  capsule,  holding  the  kidney  loosely  in  a  net- 
work of  fasciculi,  which  allows  the  kidney  some  motion 
within  it,  but  yet  moves  with  it,  and  may  be  pulled  down- 
ward by  its  lower  attachment  to  the  bowel ;  and,  third,  we 
have  the  capsule  of  Gerota  surrounding  the  fatty  capsule, 
excepting  at  its  inner  side  and  below,  where  it  becomes 
attenuated  and  merges  with  the  nephrocolic  ligament  at 
its  attachment  to  the  ascending  colon.  (Figs.  11,  12.) 
The  kidney,  in  its  excursions,  must  thus  carry  with  it 
both  the  fibrous  capsule  and  the  fatty  capsule,  but  the 
capsule  of  Gerota,  being  fixed,  remains  in  place,  and,  be- 
ing open  at  its  inner  aspect,  allows  the  kidney  to  pass 
out  of  its  embrace  in  that  direction.  This  formation  of 
Gerota's  capsule,  with  resultant  action  of  the  loose  kid- 
ney, explains  the  cause  of  the  discomfort  experienced  by 


42  NEPHROCOLOPTOSIS. 

many  patients  suffering  from  nephroptosis  when  lying  on 
the  left  side. 

The  Large  Intestine. 

The  large  intestine  (Fig.  3)  is  that  part  of  the  ali- 
mentary canal  which  connects  the  small  intestine,  ending 
at  the  ileocecal  valve,  with  the  anns,  and  is  from  five  to 
six  feet  in  length.  It  is  readily  distinguished  from  the 
small  intestine  by  its  sacculated  contour  and  its  longi- 
tudinal muscular  bands,  as  well  as  by  the  greater  thick- 
ness of  its  walls.  Tn  its  normal  position  it  is  horse-shoe 
shaped,  with  the  curve  uppermost,  and  extends  from  the 
right  iliac  region  upward  to  the  under  surface  of  the 
liver,  then  across  the  abdomen — under  the  liver,  stomach, 
and  spleen — to  the  left  side,  where  it  passes  down  and 
over  the  brim  of  the  pelvis  to  its  outlet,  the  anus.  It  has 
three  flexures — viz. :  the  hepatic  flexure,  the  splenic  flex- 
ure, and  the  sigmoid  flexure — the  first  two  signifying  the 
angles  which  the  bowel  forms  in  passing  respectively 
from  ascending  to  transverse  (at  the  liver)  and  from 
transverse  to  descending  (at  the  spleen),  and  the  third, 
situated  in  the  pelvis,  at  the  termination  of  the  descend- 
ing colon,  so  called  because  of  its  fancied  resemblance  to 
the  Greek  letter  sigma,  ^  These  flexures  are  all  im- 
portant anatomical  points  in  the  bowel,  as  they  are  so 
frequently  concerned  in  occlusions  and  constipation;  but, 
as  the  pathological  conditions  under  consideration  prac- 
tically implicate  no  structure  lower  than  the  splenic  flex- 
ure and  the  beginning  of  the  descending  colon,  only  the 
hepatic  and  splenic  flexures  need  be  especially  consid- 
ered in  this  connection. 

The  large  intestine  is  supported  in  its  position  in  the 
abdomen  centrally  by  its  mesentery,  laterally  by  its  peri- 
toneal  attachments    (occasionally  partly  by  mesentery 


ANATOMY  AND  PATHOLOGY.  43 

also),  and  to  a  considerable  extent,  in  the  opinion  of  the 
author,  by  the  nephrocolic  ligament.  The  large  intestine, 
at  the  hepatic  flexure,  passes  in  front  of  the  lower  pole  of 
the  right  kidney,  to  which  it  is  attached  by  the  nephro- 
colic ligament  (which  is  situated  between  its  peritoneal 
attachments),  and  on  the  opposite  side  it  is  in  about  the 
same  relation  with  the  left  kidney  at  the  splenic  flexure, 
being  attached  to  it  in  like  manner  by  the  nephrocolic 
ligament.  The  most  important  points  of  support  de- 
rived from  the  peritoneum  consist  of  two  folds  of  this 
membrane,  a  fold  situated  at  either  end  of  the  transverse 
colon.  They  serve  mainly  to  hold  the  gut  suspended  in 
its  upper  position  in  the  abdomen.  These  folds  are 
known  as  the  hepatocolic  and  phrenocolic  ligaments. 
Gray  says  the  hepatocolic  ligament  is  not  invariably 
present.  The  hepatic  and  splenic  flexures  are  apparently 
formed  by  the  upward  pull  of  these  two  ligaments  at  the 
respective  ends  of  the  transverse  colon,  and  become  very 
important  etiologic  factors  in  connection  with  the  sub- 
ject of  nephrocoloptosis.  The  bowel  is  further  supported 
on  each  side  by  the  nephrocolic  ligaments,  which  connect 
the  kidney  on  the  right  side  to  the  posterior  wall  of  the 
ascending  colon,  and  the  kidney  of  the  left  side  to  the 
posterior  wall  of  the  descending  colon. 

The  diameter  of  the  large  intestine  decreases  from  the 
cecum,  where  it  is  about  three  inches,  to  the  descending 
co]on,  where  it  is  about  one  and  one-half  inches.  The 
divisions  of  the  large  intestine  are  the  cecum,  ascending- 
colon,  transverse  colon,  descending  colon,  sigmoid  colon 
or  flexure,  and  rectum.  The  cecum  is  the  blind  sac  which 
forms  the  end  of  the  bowel  and  receives  the  contents  of 
the  ileum  through  the  ileocecal  valve.  The  ascending 
colon  is  that  portion  which  extends  from  the  cecum  to  the 
spenic  flexure  at  the  hepatocolic  ligament. 


44  NEPHEOCOLOPTOSIS. 

The  cecum  and  ascending  colon  together  form  a  most 
important  and  interesting  part  of  the  large  intestine,  for 
this  portion,  unlike  the  remainder  of  the  gut,  performs  a 
very  important  part  of  the  process  of  digestion  and  ab- 
sorption. It  is  here  that  the  reverse  peristalsis  occurs, 
producing  the  "churning"  action  of  the  bowel,  which 
makes  it  possible  for  this  sac,  with  its  only  outlet  upward, 
to  absorb  the  large  quantity  of  fluid  poured  into  it  from 
the  small  intestine  through  the  ileocecal  valve.  This 
part  of  the  bowel  is  the  most  richly  supplied  with  lym- 
phatics, and  is  apparently  designed  to  finish  the  process 
of  absorption,  passing  the  residue — the  waste  and  useless 
matter — along  into  the  remainder  of  the  bowel,  which 
acts  simply  as  a  reservoir,  holding  it  only  until  it  can  be 
evacuated. 

With  this  understanding  of  the  office  of  the  cecal  end 
of  the  colon,  it  can  be  readily  seen  that  any  interference 
with  the  normal  mechanics  of  its  function  would  cause 
serious  derangement  of  the  parts  and  consequent  dis- 
turbance of  normal  nutrition,  to  say  nothing  of  discom- 
fort, distress,  and  annoyance  caused  by  the  disturbed  ac- 
tion of  the  musculature  of  the  parts  incident  to  such  in- 
terference. 

The  transverse  colon  is  that  section  of  the  bowel  which 
passes  across  the  upper  abdomen  from  the  hepatic  flexure 
to  the  left  side,  ending  at  the  splenic  flexure.  The  de- 
scending colon  is  that  part  which  commences  at  the 
splenic  flexure  and  passes  down  close  to  the  left  parietes 
to  the  sigmoid  flexure  at  a  level  with  the  crest  of  the 
ileum.  The  sigmoid  flexure  lies  below  this  latter  point 
and  terminates  in  the  pelvis  with  the  rectum  and  anus. 

The  combined  form,  position,  attachments  to  the  body, 
and  peculiar  office  of  the  colon  result  in  its  easy  displace- 
ment, which  is  attended  with  a  greater  consequent  de- 


ANATOMY  AND  PATHOLOGY.  45 

rangement  of  function  than  obtains  in  the  displacement 
of  any  other  part  of  the  alimentary  canal.  Its  position 
being  semi-fixed,  and  its  contents,  beyond  the  hepatic 
flexure,  semi-solid,  and  not  freely  moved  by  peristalsis — 
as  is  the  case  with  the  fluid  contents  of  the  small  intes- 
tine— any  displacement  which  causes  unusual  angulation, 
it  can  be  readily  seen,  would  result  in  defective  elimina- 
tion of  its  contents.  Its  fixed  jposition,  in  connection  with 
the  fact  that  it  must  be  of  a  definite  leng-th  to  fill  a  given 
space,  renders  the  question  of  its  distention  and  elonga- 
tion— which  occurs  as  a  result  of  long  continued  partial 
occlusion  by  angulation,  etc. — a  matter  of  serious  impor- 
tance, and  one  to  be  duly  considered  in  connection  with 
these  anatomic  conditions. 


The  Duodenum. 

The  duodenum  (Figs.  3,  4,  5,  6)  is  that  portion  of  the 
small  intestine  which  passes  from  the  pyloric  end  of  the 
stomach  to  the  jejunum.  It  is  about  ten  inches  in  length 
and  about  two  inches,  or  less,  in  diameter,  runs  a  tor- 
tuous course,  is  covered  only  in  part  by  the  peritoneum, 
and  differs  essentially  in  position  from  the  remainder  of 
the  small  intestine,  being  almost  completely  fixed  and 
immovable.  It  is  this  immobility,  coupled  with  the  fact 
of  its  adhesion  to  the  fatty  capsule  of  the  right  kidney, 
which  makes  this  portion  of  the  small  intestine  an  im- 
portant factor  in  the  somewhat  complex  pathology  of 
nephrocoloptosis.  The  gut,  soon  after  it  leaves  the 
stomach,  passes  under  the  transverse  mesocolon,  and  is 
within  its  embrace  during  the  remainder  of  its  nearly 
circular  course,  passing  through  it  and  becoming  intra- 
peritoneal again  at  its  junction  with  the  jejunum.  The 
bowel  is  further  held  by  the  suspensory  muscle,  a  deli- 


46  NEPHKOCOLOPTOSIS. 

cate,  flat,  fibromuscular  band,  whicli  starts  from  the  left 
crus  of  the  diaphragm  and  runs  downward  to  its  inser- 
tion on  the  duodenojejunal  angle.     (Fig.  5,  No.  2.) 

The  common  bile  duct  (Fig.  6,  No.  2)  empties  into  the 
gut  shortly  after  it  becomes  extra-peritoneal,  and  the 
head  of  the  pancreas  lies  within  its  concavity  and  is  ad- 
herent to  it.  It  is  thus  readily  seen  what  effect  the  trac- 
tion of  the  descending  and  adherent  kidney  must  have 
on  the  duodenum,  held,  as  it  is,  rigidly  at  two  points — 
the  first  near  its  origin  at  the  stomach  by  its  attachment 
to  the  hepatoduodenal  ligament  and  by  the  edge  of  the 
transverse  mesocolon  where  it  passes  under  it,  and  the 
second  at  the  duodenojejunal  angle  by  the  suspensory 
muscle.  The  result  is  angulation  of  the  gut  at  these 
points,  as  well  as  the  causation  of  more  or  less  distortion 
of  the  conmion  bile  duct,  with  consequent  disturbance  of 
the  normal  hepatic  and  pancreatic  functions.    (Figs.  4,  6.) 

The  stomach  (Figs.  3,  4),  when  of  normal  size,  should 
not  be  in  a  position  for  any  portion  of  it  to  be  found  be- 
low the  umbilicus,  except,  perhaps,  in  some  instances  of 
acute  overdistention.  The  organ  is  said  to  be  in  a  state 
of  ptosis  when  the  greater  curvature  is  found  to  be  at  or 
below  the  navel,  whereas  the  stomach  is  not  usually 
really  dropped,  but  is  in  a  state  of  dilatation,  and,  be- 
cause of  its  increased  size,  the  dependent  portion  is  found 
in  this  abnormally  low  position.  The  cardiac  end  is  still 
held  in  its  fixed  position  at  the  termination  of  the  esoph- 
agus, and  the  pyloric  extremity  is  held  solidly  by  the 
fixed  position  of  the  duodenum,  especially  at  the  point 
where  this  bowel  passes  across  and  under  the  transverse 
mesocolon  and  at  the  point  of  attachment  of  the  hepato- 
duodenal ligament — about  an  inch  from  the  pylorus. 
This  latter  is  the  important  anatomic  point  which  is  of 
interest  in  connecting  the  stomach  with  the  chain  of 


ANATOMY  AND  PATHOLOGY.  47 

pathology  beginning  with  the  relaxation  of  the  hepato- 
colic  ligament,  as  it  is  the  compression  of  the  duodenum 
at  this  point,  before  described,  which  causes  gastric  stasis 
and  consecpient  dilatation,  and  the  so-called  gastroptosis. 
The  elongation  of  the  gastrohepatic  omentum,  which  may 
be  more  or  less  relaxed  as  a  consequence  of  the  constitu- 
tional condition  of  weakness  of  restraining  tissues,  grad- 
ually eventuates  as  the  unusual  strain  put  upon  it  by  the 
increasing]}^  enlarging  stomach  continues. 


CHAPTEE  II. 
ETIOLOGY. 

The  perfect  construction  of  a  well-designed  macMne  re- 
quires that  it  shall  be  so  made  as  to  perform  its  work 
loroperly,  and  at  the  same  time  to  continuously  do  its 
work  for  a  reasonable  i^eriod  without  breaking  down  or 
getting  out  of  order.  That  these  purj^oses  may  be  ful- 
filled, the  first  requisite  that  the  designer  insists  on  is  that 
the  materials  used  shall  be  of  the  quality  best  adapted  to 
the  uses  of  the  various  parts  of  the  mechanism.  An 
imjDerfectly  tempered  spring,  die,  or  cam  results  in  im- 
perfect working  of  the  machine,  if  not  in  utter  failure. 

The  human  body  may  be  compared  to  a  well-designed 
machine,  but  it  must  be  constructed  according  to  specific 
requirements  in  order  to  enable  it  to  perform  its  given 
work  in  a  perfect  manner — the  functions  of  the  various 
parts  must  be  performed  in  harmony,  and  the  purely  me- 
chanical parts  must  operate  without  friction  or  failure, 
and  not  break  or  yield  when  subjected  to  the  normal 
strains  of  the  working  machine.  While  this  human 
machine  has  been  well  designed,  its  construction  is  not 
alwaj^s  in  accordance  with  its  requirements,  and  the  re- 
sults are,  naturally,  variable — one  will  succumb  to  the 
first  strain  almost  as  soon  as  finished,  some  vital  part  in 
such  an  instance  having  inherited  the  tissue  too  frail  to 
do  its  |)art  in  the  work  of  life.  Defective  construction  in 
others  may  be  manifested  in  functional  disorders,  leading 
to  incomplete  metabolism,  gout}^  diathesis,  tubercular 
tendencies,  etc. ;  or  the  lack  of  structural  integrity  may  be 
marked  in  the  jDurely  mechanical  tissues — those  which 

48 


ETIOLOGY.  49 

have  to  do  with  the  binding  together  of  different  parts, 
the  sustaining  tissues — aponeurosis,  fascia,  tendon,  and 
muscle.  In  this  manner  the  tendency  to  hernia,  uterine 
displacements,  lateral  curvature  of  the  spine,  prolajpse  of 
the  internal  organs  of  the  body,  etc.,  may  be  transmitted 
by  heredity  as  well  as  a  crooked  nose,  imperfect  teeth,  or 
other  impro23erly  constructed  anatomy.  A  man  says  he 
has  a  hernia  caused  by  a  strain,  whereas  the  strain  was 
but  a  contributing  incident,  while  the  real,  the  funda- 
mental, cause  of  his  rupture  existed  before  he  was  born — 
even  at  the  inception  of  his  existence,  concealed  in  the 
germinated  ovum.  It  would  appear,  therefore,  that  the 
causes  of  displacement  of  internal  organs  are  both  pas- 
sive and  active — the  former  being  the  primary,  or  funda- 
mental, etiologic  factor,  and  the  latter  the  secondary,  or 
contributory,  causes.  Finely  drawn  theories  and  elabo- 
rate arguments  are  not  necessary  to  substantiate  this  po- 
sition, as  clinical  evidence  in  its  favor  is  abundant.  The 
author  has  one  family  of  three  generations  under  his  care 
in  which  nephrocoloptosis  occurs  in  the  grandmother, 
mother,  and  two  daughters.  This  is  not  a  coincidence, 
but  the  outcome  of  natural  law. 

On  the  other  hand,  it  does  not  seem  reasonable  that  the 
small  weight  of  the  kidney  alone  is  sufficient  to  cause  its 
displacement,  even  when  loosely  secured,  and  so  we  must 
look  to  the  secondary  or  contributing  causes  for  the  link 
to  complete  the  causative  chain.  To  prove  it  when  found, 
it  must  be  always  present  with  the  nephroptosis,  and  its 
action  must  be  positive — mechanically  positive.  In  colo- 
ptosis  and  in  the  action  of  the  nephrocolic  ligament  these 
conditions  are  fulfilled.  This  conclusion  is  substantiated 
by  the  evidence  of  the  author's  radiographic  investiga- 
tions, which  show  coloptosis  present  in  all  of  a  large  num- 
ber of  cases  of  nephroptosis  examined. 


50  NEPHEOCOLOPTOSIS. 

Tliat  the  kidney  is  infiiiericed  by  tlie  bowel,  aud  uot  the 
bowel  by  the  kidney,  is  proved  by  the  fact,  as  stated,  that 
all  the  eases  of  iDrolajDsed  kidney  had  also  prolajDsed 
bowel,  while  a  number  of  radiographs  showed  lorolapsed 
bowel  with  normalh'  jDlaced  kidnej^,  which  is  an  indorse- 
ment of  Glenard's  theory.  The  presence  and  action  of 
the  nephro colic  ligament  makes  it  the  most  important 
factor  in  connection  with  the  secondary  or  contributory 
causes,  as  by  it  the  prolapsing  colon  pulls  the  kidney  out 
of  place. 

The  factors  necessary  for  the  occurrence  of  nephrocolo- 
ptosis  are  four  in  number,  viz.:  (1)  weak  or  absent  hep- 
atocolic  ligament,  (2)  loose  attachment  of  kidney  at  its 
hilum  and  to  Gerota's  cajDSule,  (3)  strong  and  short  neph- 
rocolic  ligament,  and  (4)  prolapse  of  cecum  and  ascend- 
ing colon.  Without  this  combination  the  kidney  will 
not  be  displaced,  except  by  trauma.  If  the  kidney  is 
bound  strongly  to  the  back  by  the  tissues  around  the 
hilum  and  blood  vessels,  and  to  the  perinephric  fascia 
(Gerota's  capsule),  as  usuall}'  found  in  post-mortem,  it 
should  not  be  only  impossible  to  dislodge  it  by  traction, 
but,  with  a  strong  nephrocolic  ligament,  this  mechanical 
arrangement  should  assist  in  preventing  a  coloptosis,  and 
this  is  the  normal  mechanical  action  of  these  parts. 

Reference  to  the  radiographs  of  cases  will  show  that 
the  laxity  of  the  peritoneal  attachment  of  the  colon  at  the 
hepatic  flexure  is  the  key  to  the  whole  line  of  descensus. 
When  this  gives  way,  the  cecum  and  ascending  colon 
drop,  and  the  drag  on  the  kidney  through  the  nephrocolic 
ligament  begins.  Hence  the  conclusion  is  reached  that 
the  right  kidney  does  or  does  not  descend  according  to 
the  laxity  of  its  supports  and  the  degree  of  traction  ex- 
erted on  it  by  the  dropping  of  the  ascending  colon  and 
cecum,  which  is  permitted  by  a  lax,  or  absent,  hepato- 


ETIOLOGY.  51 

colic  ligament.     Tlie  cecum,  consisting  of  a  sac  with  its 
outlet  upward,  necessitates  the  contents  of  the  viscus  to 
be  always  forced  in  that  direction,  which  recjuires  the 
application  of  tractile  force  in  the  opposite  direction,  and 
through  the  nephrocolic  ligament  the  kidney  is  pulled 
downward.     (Figs.  3,  4,   5,   6.)     AVhen  to  this  natural 
downward  traction  of  the  bowel  is  added  the  weight  of 
a  full  torpid  cecum,  distended  more  or  less  with  fecal 
matter,  the  force  applied  to   the  downward  movement 
of  the  kidney  will  1)e  still  greater.     The  violent  efforts 
of  the  bowel   to  unload  itself  when   so  distended,   and 
to  forccrthe  contents  over  the  acute  angle  at  the  hepatic 
flexure,  formed  by  the  descent  of  the  gut  on  each  side, 
aid  materially  in  the  completion  of  this  etiologic  factor. 
The  action  of  the  colon  on  the  left  side  is  in  the  opposite 
direction,  and  its  contents  are  there  forced  downward, 
thus  making  no  countertraction  on  the  kidney  of  this 
side  through  the  nephrocolic  ligament.     The  phrenocolic 
ligament,  which  supports  the  bowel  at  the  splenic  flexure, 
is  also  an  important  factor  in  the  prevention  of  displace- 
ment of  the  gut  at  this  point,  as — unlike  the  hepatocolic 
ligament — it  is  always  present,  and  uniformly  strong  and 
dependable.     In  consequence  of  these  favorable  mechan- 
ical conditions  the  left  kidney  is  rarely  dislodged.     When 
the  right  kidney  is  forced  downward  by  the  dropped  as- 
cending colon,  it  pulls  with  it  the  duodenum  by  reason  of 
the  adhesion  of  this  intestine  to  the  side  of  the  fatty  cap- 
sule, and  this  action,  causing  a  kink  or  angle  in  the  bowel 
and  often  closure  of  the  biliary  and  pancreatic  ducts,  ex- 
plains the  presence  of  digestive  and  biliary  symptoms  in 
cases  of  prolapse  of  the  right  kidney.    Prolapse  of  the  left 
kidney  alone  is  exceedingly  rare,  and  when  it  does  occur 
from   any   cause,    except   trauma,    gives   practically   no 
symptoms.     As  the  author  has  never  found  a  left  dislo- 


52  NEPHROCOLOPTOSIS. 

cation  singly,  and  but  eleven  cases  of  floating  kidney  of 
the  left  side  in  one  hundred  and  fifty-three  nephroptoses 
of  the  right,  there  mnst  be  some  good  reason  for  the  great 
difference.  The  weak  jDoint  of  construction  in  the  hepato- 
colic  ligament,  the  presence  of  the  nephrocolic  ligament, 
and  the  action  of  the  ascending  colon  and  cecum  explain 
this  in  the  most  satisfactory  manner.  As  a  purely  me- 
chanical proposition  it  can  not  be  refuted  if  the  presence 
of  the  ligament  is  admitted.     (Figs.  3,  4,  5,  6.) 

Goloi^tosis  without  nephroptosis  is  due  to  the  presence 
of  a  long,  loose,  nephrocolic  ligament,  which  allows  the 
bowel  to  descend  without  making  traction  on  the  kidney. 
This  has  been  found  to  be  true  in  several  operations  for 
the  cure  of  constipation  and  colonic  irritability  in  cases 
of  coloptosis  without  nephroptosis. 

Much  has  been  said  of  late  regarding  the  body  shape  as 
a  cause  of  nephro]3tosis,  and  deductions  have  been  made 
based  on  elaborate  measurements  and  mathematical  cal- 
culations, but  this  theory  has  been  found  to  be  of  little 
]3ractical  use  from  either  an  etiologic  or  diagnostic  stand- 
point. While  a  large  number  have  the  conformation  of 
body  described,  many  do  not  fill  the  requirements  at  all, 
so  that  the  author  has  come  to  look  upon  the  imperfectly 
developed  body  in  these  cases  as  due  to  the  same  primary 
cause  as  the  ptoses  which  are  so  frequently  found  asso- 
ciated with  it — viz. :  hereditary  laxity  of  restraining  tis- 
sues. Therefore,  the  body  shape  should  not  be  consid- 
ered in  any  sense  as  a  primar}^  cause,  but  simjjly  as  a 
concomitant  condition.  It  acts,  no  doubt,  to  a  consider- 
able extent  as  a  secondary  or  predisposing  cause,  and  in 
the  therapeusis  should  receive  treatment  as  such. 


CHAPTEE  III. 

SYMPTOMATOLOGY. 

The  symptoms  caused  by  the  displaced  colon  and  kid- 
ney are  so  complex  and  their  manifestations  so  varied 
that  the  patient  is  liable  to  be  treated  for  all  manner  of 
ailments  which  do  not  exist,  and  frecpiently  gives  a  his- 
tory of  having  ''suffered  with  many  physicians" — con- 
sulting doctors  of  all  kinds,  and  each  finding  good  symp- 
tomatic grounds  for  classifying  the  i^atient  in  his  special- 
ty. The  gastro-enterologist  now  gets  the  most  of  them, 
with  the  neurologist  (or  psychiatrist)  a  close  second. 
The  surgeon  has  been  making  a  rather  unsuccessful  bid 
for  them  by  his  nephropexies,  which  failed  so  frecpiently 
because  his  pathologic  vision  took  him  no  farther  than 
the  loose  kidney. 

An  intelligent  consideration  of  the  true  etiology  makes 
plain  the  understanding  of  the  symptomatic  manifesta- 
tions which  lead  to  correct  diagnosis  and  prognosis,  and 
to  practical  and  efficient  treatment.  Hence,  to  under- 
stand the  symptoms  and  know  what  they  mean  we  must 
know  what  causes  them.  The  first  s^miptoms  indicative 
of  a  nephrocoloptosis  are  usually  not  those  referable  to 
the  kidney,  but  to  the  stomach  or  colon.  Because  of  the 
traction  on  the  duodenum,  with  resultant  angulation  of 
the  bowel  and  interference  with  the  function  of  the  bili- 
ary and  pancreatic  ducts,  gastric  manifestations  will  be 
the  most  likely  to  be  the  first  in  evidence,  and  a  super- 
ficial diagnosis  made  of  "indigestion"  and  "biliousness." 
The  symptoms  are  those  ordinarily  ascribed  to  dyspepsia 
—distress  after  eating  (referred  to  the  right  epigastric 

53 


54  NEPHEOCOLOPTOSIS. 

region),  eructation  of  gas,  occasional  nausea,  etc.  The 
complexion  becomes  muddy,  or  a  slight  jaundice  may 
occur. 

The  resultant  loss  of  flesh  and  a  general  appearance  of 
malnutrition  soon  show  markedly  the  result  of  the  de- 
rangements of  the  digestive  system.  Concurrently  with 
the  gastric  manifestations,  or  possibly  preceding  them, 
there  will  occur  those  referable  to  the  colon,  caused  by  its 
angulations  and  resultant  sacculations  and  stasis  of  gas 
and  fecal  matter.  The  most  immobile  points  of  attach- 
ment of  the  colon  are  at  the  hepatic  and  splenic  flexures, 
so  that  when  the  cecum  and  transverse  colon  become  dis- 
placed, and  lie  low  in  the  abdomen  and  pelvis,  these  two 
high  attached  portions  of  the  bowel — being  hung  up,  as  it 
were,  like  a  rubber  tulie  over  a  peg — cause  sharp  angu- 
lation in  each  upper  h3q3ochondriac  region,  which  partial 
obstruction  of  the  bowel  at  these  points  causes  the  prin- 
cipal colonic  symptomatology.  Pain  is  usually  com- 
plained of  at  the  points  of  flexion,  and  assumes  at  times 
a  severe  colicky  character,  that  on  the  left  side  often  be- 
ing the  most  marked  and  of  a  more  severe  character, 
which  is  doubtless  caused  l)y  the  greater  mechanical 
obstruction  being  at  that  point,  as  a  result  of  the  sag 
of  the  transverse  colon  toward  this  side,  due  to  the  re- 
laxation of  the  hepatocolic  ligament,  thus  bringing  the 
greatest  weight  of  the  bowel  to  hang  on  this  support. 
(Figs.  4,  6,  and  radiographs  of  cases.) 

The  difficulty  experienced  by  the  cecum  in  evacuating 
its  contents  frequently  causes  severe  pain,  with  spastic 
contraction  of  the  gut,  which  is  sometimes  so  severe  as  to 
simulate  peritonitis,  or  appendiceal  disease.  During  such 
attacks  the  distended  sensitive  cecum  can,  as  a  rule,  be 
easily  demonstrated  by  palpation,  and,  as  its  descensus 
mav  be  so  extensive  as  to  cause  it  to  lie  in  the  bottom 


SYMPTOMATOLOGY.  55 

of  the  pelvic  cavity,  the  position  of  the  fulhiess  and  sensi- 
tiveness may  be  deceptive  and  lead  to  faulty  diagnosis. 

The  toxemia  resulting  from  stasis  of  the  colonic  con- 
tents, and  the  constant  activity  of  the  colon  in  its  efforts 
to  free  itself  of  the  overdistention  by  forcing  its  contents 
over  these  angles,  causes  a  condition  of  chronic  irrita- 
bility of  all  of  the  structural  parts  of  the  bowel,  besides 
toxic  symptoms  of  more  or  less  severity.  The  mucous 
membrane  is  the  first  to  suffer,  then  the  musculature,  and 
lastly  that  portion  of  the  sympathetic  nervous  system 
supplying  the  gut.  The  indications  will  be:  (1)  colonic 
catarrh,  as  shown  by  masses  of  mucus  in  the  stools,  obsti- 
nate constipation,  and  frequently  alternating  diarrhea 
and  constipation;  (2)  frequent  attacks  of  colic,  often  of 
long  duration  and  of  severe  character,  causing  sensitive- 
ness of  the  colonic  region  for  long  periods  of  time;  (3) 
nervous  manifestations  of  various  kinds  and  degrees  of 
severity,  among  which  the  most  common  are  sudden  at- 
tacks of  headache  or  vertigo,  hysteria  in  various  forms, 
tachycardia  (very  common,  often  occurring  at  night  dur- 
ing sleep,  causing  a  sudden  awakening  with  feeling  of 
impending  danger),  insomnia,  loss  of  menior}^,  and  mental 
irritability.  In  cases  of  long  standing  a  condition  of 
neurasthenia  often  develops  that  may  lead  to  the  most 
extensive  serious  disorders  of  the  nervous  system,  even 
to  the  derangement  of  the  reasoning  faculties. 

A  comprehensive  and  forceful  opinion  regarding  the 
disturbance  of  the  nervous  system  related  to  conditions 
under  consideration  is  the  following  by  G.  B.  Burr,  M.  D., 
medical  director  of  Oak  Grove  Hospital  for  Nervous  and 
Mental  Diseases,  Flint,  Mich.: 


56  IsTEPHEOCOLOPTOSIS. 

Psychopathic  Nephroenteroptic  Symptomatology. 

The  theory  of  autotoxis  as  a  causative  factor  in  the  psychoses 
and  neuroses  has  furnished  a  working  basis  for  the  explanation 
of  certain  departures  from  the  normal  in  the  cerebro-spinal 
sphere  of  activity.  That  the  theory  has  been  overloaded,  possi- 
bly goes  without  saying.  This  is  unfortunately  true  of  every 
illuminating  theory,  but  many  pursuing  the  treatment  of  nervous 
and  mental  maladies  are  reasonably  well  assured  that  deductions 
from  the  favorable  action  of  eliminatives  post  hoc  justify  the  fur- 
ther propier  hoc  assumption  of  the  causative  relation  of  retained 
toxins  to  nervous  perturbation. 

Constipation  is  a  bane  of  mankind,  and  seems  unavoidable 
under  present-day  conditions  of  living  and  work.  It  is  espe- 
cially the  bane  of  womankind,  and  is  often  developed  at  an  early 
period  of  life  through  inadequate  or  indecent  toilet  facilities  in 
the  public  schools.  "AYe  have  taken  your  advice  and  built  our 
new  school-house  around  the  Avater-closet, "  said  an  experienced 
member  of  a  Board  of  Education  to  the  writer  on  one  occasion. 

Constipation  is  indubitably  a  factor  in,  if  not  the  ultimate 
cause  of,  a  frightfully  large  proportion  of  mental  cases.  Its 
correction  and  the  relief  of  incidental  malassimilation  are  ends 
to  which  the  experienced  psychiatrist  directs  early  effort.  Real- 
izing the  importance  of  elimination,  it  is  impossible  to  refrain 
from  a  congratulatory  expression  to  the  author  of  this  book  for 
his  painstaking  directions  for  the  medical  relief  of  intestinal 
torpor.  Symptomatically  the  nervous  case  is  invariably  im- 
proved by  skillful  attention  to  abdominal  conditions  arising  from 
constipation.  Is  your  mental  patient  restless — attend  to  the 
bowels.  Is  he  irritable — attend  to  the  bowels.  Acquaint  your- 
self with  the  condition  of  the  teeth,  the  ears,  the  eyes,  the  chest 
organs,  the  kidneys — but  incidentally  unload  the  bowels.  Is  he 
sleepless — see  that  the  bowels  are  active.  Is  he  lacking  appetite 
— empty  the  bowels.  In  the  experience  of  the  writer  the  best 
hypnotic  is  ofteii  a  dose  of  castor  oil,  and  the  best  tonic  a  colon 
tlushing.  Elimination  and  again  elimination — ton  jours  elimina- 
tion should  be  the  watchword  in  the  treatment  of  morbid  mental 
states. 

It  is  probable  that  fecal  impaction  of  large  amount  is  a  more 
frequent  condition  than  is  generally  recognized.   Experience  in 


SYMPTOMATOLOGY.  57 

many  cases — one  very  recent — indicates  that  impaction  may  be 
present  in  extreme  degree  Avithout  obvions  abdominal  indications 
pointing  to  colonic  distention.  Nurses  may  be  deceived  by  the 
appearance  of  regularity  in  patients'  stools,  Avhile  emptying  the 
intestinal  canal  at  higher  levels  than  the  sigmoid  does  not  occur. 
"When  through  Avell-directed  effort  this  finally  takes  place,  the 
amount  of  fecal  accunuilation  may  be  astounding. 

That  perverted  emotional  states  in  relatively  healthy  individu- 
als may  be  induced  I^y  temporary  bowel  inactivity  needs  no  dem- 
onstration to  one  ha])itually  regular  in  this  function.  Prevented 
from  its  performance,  there  are  irritability,  hebetude,  lassitude, 
malaise,  vaso-motor  perturbation;  the  person's  mental  output  is 
indifferent  and  his  emotional  responsiveness  is  unstable.  Add 
to  the  sensations  thus  induced  the  results  of  months  or  years  of 
habitual  constipation,  and  it  is  not  difficult  to  understand  how 
morbid  habits  of  thinking  may  be  augmented,  if  not  engendered, 
by  chronic  bowel  torpor. 

It  follows  logically  that  any  structural  impediment  to  peristal- 
sis should,  if  possible,  be  relieved,  and  that  if  relieved  the  symp- 
toms dependent  upon  it  will  improve.  Mechanical  difficulties 
(obstructions)  that  surgery  can  reach  should  be  relegated  to  the 
hands  of  the  operator.  The  writer  has  no  interest  in  that  con- 
ception of  surgery  which  constitutes  it  the  be-all  and  end-all  in 
treatment.  Patients  subjected  to  ill-advised  operation  are  ren- 
dered worse  instead  of  better.  The  efficient  and  helpful  surgeon 
to  nervous  and  mental  cases  must  needs  repress  the  enthusiasm 
for  operating  and  intelligently  apply  common-sense  principles  in 
their  care  and  medication.  Many  cases  recover  after  surgery 
when  the  operation  is  but  an  episode.  A  morbid  condition  has 
been  relieved,  a  focus  of  irritation  removed,  and  the  patient  is 
afforded  a  benefaction  comparable  with  that  furnished  by  a 
dentist  who  extracts  an  aching  tooth.  In  addition,  the  nursing 
attention,  the  prolonged  quiet,  the  rest  in  bed,  are  all  adjuvants 
to  his  betterment. 

Again,  mental  and  nervous  cases  recover  where  obvious  and 
palpable  lesions,  as  of  the  pelvic  floor  and  uterus,  are  left  un- 
corrected. The  writer  has  been  amazed  at  the  facility  with 
which  theoretically  pure  surgical  cases  from  time  to  time  re- 
cover without  surgery;  on  the  other  hand,  he  has  observed  the 


58  NEPHROCOLOPTOSIS. 

beneficent  results  of  surgical  attention  again  and  again  in  mental 
cases.  Eectification  of  the  position  of  a  displaced  kidney  has 
been  contributory  to  the  relief  of  morbid  depression  in  a  case 
upon  which  Dr.  Longyear  operated  and  in  which  he  and  the 
writer  were  jointly  interested. 

The  pathological  connection  between  kidney  displacement  and 
morbid  mentality  has  been  heretofore  difficult  of  establishment. 
That  the  downward  dislocation  is  due,  according  to  the  ingenious 
observations  of  Dr.  Longyear,  to  a  dragging  on  the  nephrocolic 
ligament — the  primary  fault  being  one  of  displacement  of  ali- 
mentary and  emunctory  organs,  with  consequent  embarrassment 
to  their  functionating — sheds  a  flood  of  light  on  the  subject. 
The  question  resolves  itself  into  one  of  impaired  nutrition  and 
autotoxis,  and  the  sequence  of  events  in  their  etiological  bearing 
upon  morbid  processes  in  the  nervous  system  is  made  as  plain 
as  a  pikestaff.     He  who  runs  may  read  their  significance. 

The  combination  of  the  effects  of  the  colonic  disorder 
with  the  malnutrition  resulting  from  the  interference 
with  the  gastric  and  hepatic  functions  causes,  in  extreme 
cases  of  long  duration,  a  facial  expression  which  is  quite 
as  characteristic  and  tYi)ical  of  this  condition  as  the  well- 
known  facies  ovarina  is  of  ovarian  tumor.  The  muddy, 
colorless  complexion,  lusterless  eyes,  deep  facial  lines,  ex- 
pressing weariness  and  exhaustion,  and  lack  of  natural 
roundness  of  outline,  mark  the  face  of  the  patient  suffer- 
ing W'ith  nephrocolojotosis. 

Constipation  of  a  more  or  less  persistent  character, 
either  alone  or  alternating  with  diarrhea,  and  the  move- 
ments usually  accompanied  by  colicky  pain,  is  a  very 
characteristic  manifestation.  The  author  has  found  this 
condition  of  the  bowels  to  be  present  in  74  percent  of  the 
last  one  hundred  cases. 

Severe  colicky  i)ain  in  the  right  inguinal  or  lumbar 
region  may  be  caused  b}^  the  spastic  condition  of  the 
cecum,  due  to  fecal  accumulation.     This  is  of  frequent 


SYMPTOMATOLOGY.  59 

occurrence,  owing  not  only  to  the  obstructive  angle  at  the 
hei3atic  flexure,  but  also  to  the  backing  up  of  the  colonic 
contents  from  the  obstructive  angle  at  the  splenic  flexure. 
As  the  cecal  contents  are  of  a  fluid  character,  and  the 
hepatic  angulation  always  less  acute  than  that  on  the  left 
side,  serious  obstructive  symptoms  at  this  point  do  not 
occur.  Symptoms  of  obstruction  may  occur,  however,  in 
extreme  cases  of  coloptosis  by  reason  of  fecal  impaction 
in  the  transverse  colon.  The  explanation  of  this  is  seen 
in  those  radiographs  which  show  a  large  portion  of  the 
transverse  colon  situated  in  such  a  manner  as  to  lie 
almost  jDarallel  with  the  descending  part  of  the  gut.  This 
necessitates  the  forcing  of  contents  uj^ward  and  over  the 
acute  angulation  at  the  splenic  flexure.  Dilatation  of  the 
cecum  results  from  this  back  pressure,  and  causes  much 
of  the  symptomatology  referable  to  thfijdg'liL_side  of  the 
_gut.  The  author  l)elieves  that  the  majority  of  the  symp- 
toms which  are  usually  attributed  to  the  floating  kidney 
itself  are  more  properly  gastric,  duodenal,  or  colonic. 

Beyond  Dietl  's  crises  and  their  secjuelge,  the  s}' mptom- 
atic  manifestations  of  the  loose  kidney  itself  are  insignifi- 
cant and  not  of  a  serious  nature.  A  sensation  of  drag- 
ging in  the  loin,  or  of  a  constriction  just  below  the  ribs, 
and  some  tenderness  on  pressure  constitute  the  indica- 
tions which  can  be  justly  attributed  to  the  loose  kidney. 
The  severe  pain  often  complained  of  in  the  right  hypo- 
chondrium  is  usually  found,  on  critical  examination,  to 
be  located  in  the  colon  at  the  hepatic  flexure;  or  the 
duodenum  may  be  the  seat  of  irritation  because  of  the 
traction  on  it  by  the  adherent  kidney. 

Dietl's  crisis^  constitutes  the  most  severe,  acute,  and 
symptomatic  indication  of  floating  kidney.     The  attack 


1  Dietl:    "Wandernde    Nieron    und    deren    Einklemmung',"    Wiener    Medi- 
zinisclie  Woclienschrift.  1S64,  vol.  14,  pp.   36,  37,  3S. 


60  NEPHROCOLOPTOSIS. 

commences  suddenly,  with  severe  jjain  in  tlie  right  side 
at  the  site  of  the  displaced  organ,  which  becomes  swollen 
and  tender.  The  bowels  are  tymjjanitic  and  sensitive  to 
touch,  and  the  patient,  with  the  knees  drawn  up  and  an 
anxious  and  pinched  expression,  has  the  general  ai3pear- 
ance  of  one  suffering  from  the  onset  of  an  attack  of  peri- 
tonitis. Jaundice  is  sometimes  observed,  due  doubtless 
to  the  mechanical  closure  of  the  bile  duct,  either  from 
pressure  of  the  swollen  kidney  or  torsion  of  the  duo- 
denum. Nausea  and  vomiting  are  usually  prominent 
symptoms  at  the  beginning  of  the  attack.  There  is  usu- 
ally little  or  no  rise  of  temperature,  but,  after  the  lapse 
of  from  ten  to  twenty-four  hours,  fever  may  be  in  evi- 
dence, even  of  a  high  degree,  caused  by  intestinal  toxemia 
incident  to  extreme  paresis  of  the  bowel.  In  severe  at- 
tacks of  long  duration,  acute  nephritis,  pyelitis,  hydro- 
nephrosis, or  perinephritis  may  develo]3,  when  the  usual 
symptoms  pertaining  to  these  conditions  will  be  manifest. 
Micturition  is  frequent  during  the  beginning  of  the  at- 
tack, and  the  urine  may  evidence  ureteral  irritation  by 
containing  some  blood  and  epithelium.  Later,  albumin, 
casts,  blood,  and  pus  will  indicate  the  involvement  of  the 
kidney  or  its  pelvis. 

When  jaundice  is  present,  an  erroneous  diagnosis  of 
gallstone  is  liable  to  be  made,  and  the  swollen  displaced 
kidney  may  be  mistaken  for  a  distended,  inflamed  gall- 
bladder. The  tympanitic,  sensitive  abdomen,  simulating 
peritonitis,  may  also  lead  to  error  in  diagnosis  in  the 
direction  of  the  appendix,  ruptured  gall-bladder,  or  pyo- 
salpinx,  and  so  cause  the  performance  of  unnecessary 
and  harmful  surgery. 

A  case  referred  to  the  author  recently  by  Dr.  B.  E. 
Shurly  occurred  at  Harper  Hospital,  and,  as  it  presents 


SYMPTOMATOLOGY.  61 

quite  a  typical  illustration  of  an  attack  of  Dietl's  crisis, 
it  is  herewith  presented  in  detail. 

Patient,  female,  unmarried,  waitress,  aged  40 ;  admitted 
January  5,  1909,  giving  the  following  history:  Diseases 
of  childhood — measles,  mumps,  whooping-cough,  and 
scarlet  fever;  good  recovery  from  all.  When  20  years  of 
age  had  typhoid  fever,  from  which  she  made  good  re- 
covery, and  which  began  with  a  '* bilious  attack,"  at- 
tended with  great  pain  in  the  right  side,  similar  to  others 
which  she  has  had  since.  During  the  last  three  years 
these  have  become  more  frequent.  The  seizure  usually 
commences  with  severe  pain  in  the  right  hypochondrium 
and  epigastrium,  occasionally  vomiting  at  onset.  Jaun- 
dice is  usuall}^  present  and  increases  during  the  attacks, 
sometimes  markedly.  Complexion  naturally  swarthy. 
Attacks  may  last  from  two  days  to  two  weeks,  one  of 
which,  eight  years  ago,  was  extremely  severe  and  lasted 
for  about  eighteen  days.  Since  then  she  has  been  taking- 
olive  oil  and  Carlsbad  salts  to  regulate  the  bowels.  Has 
noticed  that  the  attacks  are  more  frequent  when  the 
bowels  are  constipated,  which  is  their  usual  condition, 
requiring  persistent  efforts  to  move  them.  Between  at- 
tacks she  feels  fairly  well,  although  frail  and  never  very 
strong.     Never  had  any  menstrual  or  urinary  disorders. 

Her  present  illness  commenced  ten  clays  before  ad- 
mission to  the  hospital,  with  severe  j)ain  in  right  hypo- 
chondrium, chills,  nausea  and  vomiting,  slight  headache, 
jaundice,  and  rise  of  temperature.  Says  this  is  the  first 
attack,  commencing  with  chills.  Condition  on  entering 
hospital:  jaundice,  not  intense,  but  eyes  somewhat  yel- 
low; lips  and  skin  dry;  temperature,  100°  F.;  pulse,  84; 
respiration,  24.  Pain  severe  in  epigastrium  and  right 
hypochondrium;  nauseated,  but  not  vomiting.  Abdomen 
much  distended,  tympanitic  and  tender  to  touch,  espe- 


62  NEPHEOCOLOPTOSIS. 

cially  over  the  whole  of  the  right  side.  Percussion 
showed  flatness  in  right  hypochondrium  and  resonance 
over  other  parts  of  abdomen.  The  sensitiveness  and  dis- 
tention rendered  j)alpation  of  the  swollen  kidney  impos- 
sible, and  its  contour  could  be  judged  only  by  percussion, 
which  indicated  a  mass  more  than  double  the  size  of  the 
kidney. 

Urine  by  catheter:  acid,  slightly  turbid,  dark  brown; 
specific  gravity,  1,020;  albumin  present  (small  quantity), 
bile,  few  granular  casts,  and  blood  cells. 

A  diagnosis  of  Dietl's  crisis,  caused  by  torsion  of  the 
pedicle  of  a  floating' kidney,  was  made,  and  the  following- 
treatment  ordered:  physostigmin  sulphat.  gr.  1/100, 
hypodermically  every  four  hours;  a  high  enema  com- 
posed of  glycerine  f)j,  epsom  salts  fg,  and  water  gvj,  to  be 
used  once  daily;  a  low  enema,  to  be  retained,  of  normal 
saline  solution  oviij,  given  every  two  hours;  hot  camphor 
stupes  over  the  abdomen;  heroin  gr.  1/10,  hypodermic- 
ally,  when  necessary  for  pain;  fluid  diet  (no  milk). 

After  five  days  of  this  treatment,  with  some  modifica- 
tions, the  tympanitic  distention  had  disappeared  and  the 
nausea  ceased.  A  large  sensitive  mass — the  kidney — 
could  then  be  easily  palpated  in  the  right  loin  and  extend- 
ing well  forward  into  the  abdomen.  This  gradually  di- 
minished in  size  to  nearly  the  normal  kidney  in  ten 
days  more. 

An  examination  of  this  case  later  showed  a  freely  mov- 
able kidney,  and  a  radiograph  taken  at  the  same  time 
(Fig.  83)  showed  the  cecum  in  the  pelvis  and  much  of  the 
transverse  colon  with  it. 

This  case,  while  typical  of  Dietl's  crisis,  is  an  extreme 
one,  and  is  cited  as  such;  the  usual  attack,  however,  is  not 
so  severe,  and  is  often  apparently  of  less  diagnostic  sig- 
nificance.    Frequently  the  attacks  will  last  but  a  few 


SYMPTOMATOLOGY.  63 

hours;  and  consist  mostly  of  pain  located  in  the  right  epi- 
gastric region.  Such  attacks  are  often  diagnosticated  as 
gastric  neuralgia,  or  gallstone  colic.  These  short  seiz- 
ures are  doubtless  caused  by  a  slight  torsion  of  the 
jjedicle,  of  short  duration,  with  consequent  dragging  and 
kinking  of  the  duodenum  and  common  bile  duct. 

A  floating  kidney,  even  of  the  most  extreme  character, 
may  exist  for  years  without  the  occurrence  of  this  acci- 
dent, but  as  a  ptosis  of  any  degree  is  always  subject  to 
it,  and  as  it  is  known  to  occur  in  cases  thought  to  be  of  a 
mild  degree,  prognosis  in  all  cases  should  be  guarded  and 
treatment  guided  by  this  fact. 


CHAPTER  IV. 
DIAGNOSIS. 

Successful  therapeusis — the  ultimate  aim  of  medical 
science — must  be  founded  on  correct  diagnosis.  The 
drudgery  of  painstaking  examination  can  not  be  avoided 
by  the  clinician,  as  his  ultimate  success  in  treatment  de- 
pends upon  the  accuracy  of  his  findings.  To  prescribe 
for  a  patient  for  intestinal  dyspepsia  and  neurasthenia 
without  making  a  physical  examination  is  neither  scien- 
tific nor  honest,  and  yet  the  slipshod  method  of  snap 
diagnosis  is  too  frequently  i3racticed  in  the  class  of  cases 
under  consideration. 

Snap  diagnosis  often  appears  wonderful  and  impress- 
ive when  witnessed  by  the  inexperienced,  but  such 
methodless  practice  should  have  no  place  in  the  exercise 
of  knowledge  pertaining  to  any  branch  of  the  medical  art, 
and  least  of  all  to  that  of  diseases  of  the  abdomen,  where 
error  may  lead  to  dire  disaster.  Symptoms  of  a  mild 
character,  meaningless  to  the  tyro,  may  be  of  great  diag- 
nostic value  to  the  experienced  clinician,  as  he  has 
learned — that  which  every  good  diagnostician  must 
know — the  value  of  symptoms.  This  knowledge  enables 
him  to  translate  these  ofttimes  seemingly  meaningless 
signs  into  the  language  of  disease. 

I  know  of  no  class  of  cases  in  the  field  of  pathology  that 
will  yield  a  more  fruitful  reward  for  correctness  in  diag- 
nosis, to  both  the  patient  and  physician,  than  these  en- 
teroptics,  whose  manifold  complainings  are  apt  to  be  mis- 
taken for  hypochondriasis  and  the  imaginings  of  the 
chronic  dyspeptic.     The  histories  of  these  cases  are  ex- 

64 


DIAGNOSIS.  65 

ceedingly  valuable  as  diagnostic  indices,  and  should  be 
taken  with  care,  as  it  is  the  analysis  of  the  history,  in 
connection  with  existing  symptoms,  which  points  to  the 
probable  diagnosis,  and  determines  the  necessity  of  fur- 
ther investigation  by  means  of  physical  examination. 

Such  a  history  is  usually  one  of  long-standing  dys- 
pepsia, with  constipation- — or  alternating  constipation 
and  diarrhea — gradual  loss  of  flesh,  nervous  exhaustion 
and  irritability,  muddy  comjolexion,  and  a  drawn,  weary 
expression  of  countenance,  frequent  attacks  of  griping 
pains  in  the  lower  abdomen,  often  located  in  the  region 
of  McBurney's  point;  mucus  in  the  stools,  and  often  pain 
in  the  left  upper  abdomen  in  the  region  of  the  splenic 
flexure  of  the  colon.  Occasionally  a  patient  will  tell  of 
attacks  of  terrible  pain  in  the  right  side,  attended  with 
swelling  around  the  kidney,  fever,  jaundice,  etc.,  which 
are  recognized  as  attacks  of  Dietl's  crisis.  Few  patients 
will  give  all  of  these  manifestations  pointing  positively 
to  the  kidney  and  colon,  and  many  will  exhibit  but  few. 
It  is  especially  in  such  indefinite  and  obscure  cases  that 
the  physical  examination  and  the  x-ray  will  give  the  posi- 
tive results  that  make  the  diagnosis  clear.  All  cases  hav- 
ing abdominal  symptoms  should  be  examined  physically, 
and  this  is  especially  true  of  the  obscure  cases. 

The  physical  diagnosis  of  nephrocoloptosis  is  a  simpler 
proposition  than  that  of  coloptosis  alone,  because  of  the 
easily  palpated  kidney,  and  the  fact  that  the  colon  is  al- 
ways prolapsed  when  the  kidney  is  displaced  makes  the 
coloptosis  a  foregone  conclusion  when  the  nephroptosis 
is  ascertained. 

To  palpate  the  kidney,  posture  is  of  the  greatest  im- 
portance. The  subject  must  be  in  such  a  position  that 
the  muscles  of  the  abdomen,  the  loin,  and  the  thoracic 
region  will  be  relaxed.     The  position  of  standing  with 


66 


NEPHR0C0L0PT0SI8. 


forward  bending  of  the  body,  with  arms  resting  on  some 
support,  is  found  unsatisfactory  because  of  discomfort 
to  the  patient,  if  a  woman,  and  inability  to  control  the 
muscular  movements  when  in  this  position.  The  dorsal 
and  lateral  postures,  which  the  author  uses  exclusively, 
have  none  of  these  objections,  and  serve  the  purpose  ad- 
mirably. 


Fig-.    14.      Sliowing-    technic    of   physical    exauiiiuiUon    for    nepliroptosis. 
Dorsal  decubitus.     First  position  of  examiner's  hands. 


First  place  the  patient  on  the  back,  with  a  small  pillow 
under  the  head,  the  thighs  flexed  and  heels  close  to  the 
buttocks.  Expose  the  abdomen  and  the  lower  thoracic 
region.  (Figs.  14,  18.)  Standing  on  the  left  side  of  the 
patient,  place  the  tips  of  the  fingers  of  the  right  hand  in 
the  triangular  space  in  front  of  the  right  quadratus  lum- 
borum  muscle,  and  just  below  the  twelfth  rib,  and  the 
tips  of  the  fingers  of  the  left  hand  in  front,  just  below  the 


DIAGNOSIS. 


67 


costal  margin  of  the  same  side.  Direct  the  patient  to 
take  a  deep  inspiration,  allowing  the  fingers  to  gently 
follow  the  movement  of  the  parietes.  When  inspiration 
is  full,  have  the  patient  expire  the  air  completely  from 
the  lungs,  and  as  this  is  being  done  press — at  first  gently, 
then  deeply — with  the  fingers  of  both  hands,  approximat- 
ing them  toward  each  other.     At  the  end  of  expiration  re- 


Fig.    15.      Showing    technic    of    physical    exumiiiation    for    nephroptosis. 
Dorsal  decubitus.     Second  position  of  examiner's  hands. 

place  the  fingers  of  the  left  hand  with  the  thumb  of  the 
right,  continuing  deep  compression,  and  palpate  below  for 
the  kidney  with  the  left  hand.  (Figs.  15,  19.)  This  will 
usually  dislodge  a  floating  kidney  of  any  degree  of  dis- 
placement so  that  it  can  be  felt,  either  wholly  below  the 
costal  margin  or  partially  below.  In  some  cases,  how- 
ever, failure  results,  owing  to  absence  of  muscular  relax- 
ation or  limited  action  of  the   diaphragm.     In  others. 


68 


NEPHROCOLOPTOSIS. 


Gerota's  capsule  may  prevent  a  downward  displacement, 
while  permitting  free  mobility  of  the  kidney  toward  the 
median  line. 

If  the  foregoing  form  of  examination  is  negative,  the 
lateral  position  mnst  be  tried.  Turn  the  patient  on  the 
left  side,  with  the  right  hip  showing  a  little  more  than  a 
quarter  turn;  flex  both  thighs  slightly,  the  right  one  the 


Fig.    16.      Showing'    teclmic    of   physical    examination   for   nepliroptosis. 
Lateral  decubitus.     First  position  of  examiner's  Irands. 


most;  proceed  in  the  examination  technic  as  described  for 
the  dorsal  position.  (Figs.  16,  17,  18,  19.)  This  will 
never  fail  to  bring  the  loose  kidney  to  the  palpating 


fingers. 


The  important  detail  in  any  examination  is  to  bring 
about  as  complete  muscular  relaxation  as  possible.  In 
investigation  of  the  left  side  the  examiner  may  find  it 
convenient  to  stand  to  the  right  of  the  patient,  but  as  one 


DIAGNOSIS. 


69 


becomes  expert  this  cliange  of  position  is  not  necessary. 
Sucli  an  examination  may  be  made  without  exposure. 

Generally,  the  best  method  to  determine  the  position 
of  the  stomach  is  by  the  use  of  the  radiograph,  but  when 
this  can  not  be  emjoloyed  it  may  be  quite  readily  ascer- 
tained by  percussion  and  palpation  after  inflation  with 
carbonic  acid  gas,  liberated  through  the  action  of  tar- 


Fig.    17.      Showing-   teclinic    of   physical    examination   for    neplaroptosis. 
Lateral  deculjitus.     Second  position  of  examiner's  liands. 


taric  acid  upon  bicarbonate  of  soda.  In  the  diagnosis  of 
the  displaced  colon  the  inflation  of  the  gut  will  not  be 
wholly  satisfactory.  First,  there  is  the  inconvenience  of 
using  air  or  gas  by  way  of  the  anus,  and,  when  success- 
fully emj^loyed  to  distend  the  viscus,  such  distention 
tends  to  straighten  out  and  shorten  the  gut,  and  to  give 
a  false  impression  of  the  position  of  the  bowel  when  pal- 
pated and  percussed.     Furthermore,  the  acute  angle  at 


70 


NEPHEOCOLOPTOSIS. 


the  splenic  flexure,  when  the  bowel  is  prolapsed,  favors 
obstruction  of  the  lumen  of  the  bowel  and  prevents  the 
easy  passage  of  air  beyond  the  ascending  colon.  In  the 
absence  of  other  and  better  methods,  however,  this  may 
be  resorted  to,  care  being  taken  not  to  distend  the  bowel 
to  its  utmost  capacity.  The  inflation  of  the  bowel  is  best 
accomplished  with  the  patient  in  the  dorsal  position,  and 


Fig.    IS.      Showing   techuic    of   physical    examination    for   neplii'optosis. 
First  position  of  examiner's  liands  in  botli  positions  of  the  patient. 


by  means  of  air  furnished  by  an  ordinary  Davidson 
syringe.  Slow  distention  is  preferable.  Percussion  and 
pal]jation,  made  both  before  and  after  inflation,  will  de- 
termine the  position  of  the  bowel. 

The  most  accurate  and  satisfactory  way  of  demon- 
strating the  location  of  both  the  colon  and  stomach  is  by 
the  use  of  the  x-ray.  The  radiographs  obtained  have  the 
advantage  of  showing  the  viscera  in  their  ordinarj^  state 


DIAGNOSIS. 


71 


of  distention  and  repose,  so  that  a  true  idea  may  be  had 
of  the  existing  condition.  Photographic  prints  may  also 
be  made  for  recording  cases  and  for  demonstration. 

Directions  for  Preparing  the  Patient  for  a  Radiograph. 

One  ounce  of  subnitrate  of  bismuth  in  a  pint  of  milk, 
koumiss,  or  gum  acacia  solution  is  given  from  fourteen 


Fig-.  Ill,  Sliuwiiig  Lechuic  ui  [j1i>  .sical  examination  for  nephroptosis. 
Second  position  of  examiner's  hands  in  both  positions  of  the  patient.  The 
kidney  is  held  in  ptosis  by  deep  pressure  of  the  thumb  under  the  costal 
margin  and  palpated  by  the  tips  of  the  fingers  of  the  left  hand. 

to  eighteen  hours  before  the  colon  is  to  be  rayed.  Im- 
mediately after  the  ingestion  of  the  mixture  a  radiograph 
is  taken  of  the  stomach,  and  again  at  the  expiration  of 
the  longer  time  as  the  bismuth  reaches  the  bowel.  The 
time  necessary  for  the  bismuth  to  reach  the  colon  is 
somewhat  v^ariable,  depending  largely  on  the  condition 
of  activity  of  the  intestine.     If  diarrhea  be  present,  or  if 


72  NEPHROCOLOPTOSIS. 

a  cathartic  has  been  previously  given,  the  bismuth  will 
find  its  way  much  more  rapidly  than  if  the  alimentary 
tract  has  been  undisturbed.  On  the  other  hand,  if  given 
to  a  patient  whose  bowels  have  not  acted  for  several 
days,  the  bismuth  will  fail  to  reach  beyond  the  cecum. 

For  a  radiograph  of  the  descending  colon,  sigmoid,  and 
rectum  the  bismuth  emulsion  must  be  introduced  by  the 
anus,  as  the  splenic  flexure  usually  resists  the  passage  of 
it  beyond  the  transverse  colon  when  given  by  the  mouth 
— unless  a  longer  time  is  observed,  and  then  it  will  have 
passed  beyond  the  cecum  and  no  shadow  of  this  part  of 
the  bowel  will  be  in  evidence. 

The  standing  position  should  always  be  used  when  the 
apparatus  will  permit,  as  the  displaced  organs  are  then 
in  their  most  abnormal  position  of  ptosis. 

The  following  specific  directions  for  making  the  radio- 
graphic negative  are  kindly  furnished  by  P.  M.  Hickey, 
M.  D.,  editor  of  the  American  Quarterly  of  Bontgenologi/, 
who  has  done  all  of  the  radiographic  work  in  connection 
with  the  investigation  of  this  subject: 

Technic  of  the  Examination  of  the  Gastro-Intestinal 
Tract  by  Means  of  the  Rontgen  Ray. 

In  considering  the  use  of  the  Rontgen  ray  as  an  aid  in  the  diag- 
nosis of  malpositions  of  the  abdominal  organs,  particularly  the 
stomach  and  intestines,  we  must  recollect,  first  of  all,  that  the 
plate  which  is  obtained  is  a  record  of  density  of  the  part.  When 
we  examine,  for  example,  the  chest,  we  have  the  density  of  the 
heart  forming  a  decided  contrast  to  the  density  which  is  present 
in  the  lungs,  so  that  in  this  way  we  obtain  very  marked  contrast. 
When,  however,  Ave  pass  the  Rontgen  ray  through  the  tissues  and 
organs  below  the  diaphragm,  we  find  that  the  resulting  plate,  on 
account  of  the  similar  density  of  these  parts,  shows  only  a  slight 
difference  in  its  shading.  Accordiiigly,  then,  we  must  introduce 
into  the  stomach  and  intestines  some  material  which  will  have  a 


DIAGNOSIS.  73 

much  greater  weight  than  these  soft  parts.  A  number  of  dif- 
ferent elements  and  chemicals  have  been  used  for  this  purpose, 
but  the  substance  which  has  seemed  most  suitable  has  been  either 
the  isubnitrate  of  bismuth  or  the  subcarbonate  of  bismuth. 

For  the  purpose  of  outlining  the  stomach,  one  ounce  of  sub- 
carbonate  of  bismuth  can  be  administered  either  in  watery  solu- 
tion or,  preferably,  in  a  thick  solution.  Kefir  or  koumiss  holds 
it  in  suspension  for  a  long  time.  For  the  purpose  of  affording 
a  landmark  upon  the  plate,  a  metallic  object,  as  a  small  coin, 
may  be  placed  over  the  umbilicus  and  held  in  position  by  adhe- 
sive plaster;  but,  if  the  abdominal  wall  is  pendulous,  as  in  obese 
persons,  the  metallic  marker  can  be  attached  to  the  tip  of  the 
xiphoid  cartilage.  The  plate  can  now  be  taken  either  with  the 
patient  recumbent,  Avith  the  abdomen  resting  upon  the  plate,  or, 
if  we  wish  to  know  the  amount  of  gastroptosis  which  is  present, 
we  can  make  the  plate  with  the  patient  in  a  standing  position. 

For  the  technic  of  making  the  plate  it  is  necessary  to  employ 
an  x-ray  apparatus  that  is  sufficiently  powerful  to  allow  the  ex- 
posure to  be  made  in  a  few  seconds,  while  the  patient  holds  his 
breath.  If  the  patient  is  allowed  to  breathe  during  the  time 
while  the  plate  is  being  made,  a  blurring  of  the  outlines  occurs, 
due  to  the  communicated  respiratory  movements.  If  the  exami- 
nation is  successful,  we  have  the  size,  shape,  and  position  of  the 
stomach  graphically  outlined.  The  use  of  this  method  of  ex- 
amination has  quite  revolutionized  the  ideas  of  the  medical  pro- 
fession in  regard  to  the  average  shape  and  position  of  the  stom- 
ach. From  a  large  series  of  plates  that  have  been  made  by 
numerous  observers  in  various  parts  of  the  world  it  has  been 
learned  that  the  ordinary  anatomical  illustrations  are  entirely 
at  fault. 

Owing  to  the  rapid  movement  of  the  bismuth  through  the 
small  intestine,  it  has  been  impossible,  so  far,  to  obtain  satisfac- 
tory representations  of  the  small  intestine,  except  in  cases  of 
marked  stenosis  of  this  part  of  the  gut.  "When,  however,  the 
bismuth  has  passed  on  into  the  large  intestine,  we  find  that,  owing 
to  the  slowness  of  its  passage  through  that  part  of  the  alimentary 
tract,  we  can  obtain  an  accurate  idea  of  the  position  and  angula- 
tions of  the  large  gut. 

The  length  of  time  that  it  is  necessary  to  allow  to  elapse  be- 


74  NEPHROCOLOPTOSIS. 

tween  the  taking  of  the  plate  of  a  stomach  and  the  plate  of  the 
large  intestine  will  be  found  to  vary  in  different  individuals. 
If  peristalsis  is  rapid  and  the  contents  of  the  intestine  are  passed 
along  quickly,  twelve  to  fifteen  hours  will  be  found  sufficient. 
If,  however,  the  peristalsis  is  slow,  it  will  be  found  advantageous 
to  wait  from  eighteen  to  twenty-four  hours.  The  time  of  ex- 
posure necessary  to  obtain  a  plate  of  the  large  intestine  will  be 
found  to  be  slightly  longer  than  to  obtain  a  plate  of  the  stomach, 
as  the  amount  of  abdominal  tissue  necessary  for  the  rays  to  trav- 
erse is  somewhat  greater.  In  this  plate  it  will  be  found,  also, 
that  distinctness  and  clearness  of  outline  will  be  enhanced  by 
having  the  patient  hold  his  breath  during  the  time  that  the  x-ray 
tube  is  acting. 

The  plates  which  we  obtain  of  the  large  intestine  show  the 
anatomical  construction  of  this  part  of  the  bowel,  the  position 
in  the  lower  part  of  the  abdomen  or  in  the  pelvis,  and  show 
clearly  the  degree  of  angulation  of  the  hepatic  and  splenic  flex- 
ures. 

Some  criticism  has  been  offered  on  this  method  of  examina- 
tion, due  to  the  fact  that  a  few  cases  of  unpleasant  symptoms 
have  been  reported  from  the  use  of  these  large  doses  of  bismuth. 
The  following  precautions  are  advisable :  large  doses  of  bismuth 
should  never  be  administered  to  children;  subcarbonate  of  bis- 
muth should  ah^ays  be  employed  in  preference  to  the  subnitrate, 
as  no  cases  of  unpleasant  symptoms  have  ever  been  recorded 
where  one  ounce  of  subcarbonate  has  been  given.  Where  larger 
doses  of  the  subnitrate  have  been  given,  say  two  and  three 
ounces,  symptoms  of  nitrite  poisoning  have  been  observed.  It 
is  always  best,  after  the  examination,  to  have  the  patient  take  a 
quickly  acting  cathartic  to  clear  the  bismuth  from  the  intestinal 
tract. 

As  a  substitute  for  bismuth,  various  forms  of  iron  have  been 
proposed,  but  have  not  come  into  general  use.  The  latest  sug- 
gestion is  that  zirconium  oxide  be  employed,  which  has  the  great 
advantage  of  being  nontoxic  and  of  making  a  more  contrasty 
plate.  It  is,  of  course,  necessary  in  writing  a  prescription  for 
the  bismuth  that  the  C.  P.  bismuth,  free  from  arsenic,  should  be 
insisted  upon. 

For  the  examination  of  the  plate  it  is  advisable  that  after  the 


DIAGNOSIS.  75 

plate  has  been  washed  and  dried  it  should  be  viewed  in  an  illumi- 
nating box,  with  the  observer  in  a  darkened  room.  The  contrast 
of  an  underexposed  plate,  such  as  is  sometimes  obtained  of  indi- 
viduals with  thick  abdominal  walls,  can  be  increased  by  viewing 
the  plate  at  some  dista7ice,  employing,  if  necessary,  an  opera 
glass  to  make  the  plate  seem  nearer  to  the  eye.  When  one  first 
examines  these  plates  he  is  often  struck  by  a  lack  of  detail,  which 
is  due  to  the  fact  that  he  is  unaccustomed  to  observe  what  to  an 
experienced  eye  would  be  important  points.  The  more  one  sees 
of  these  plates  and  the  more  he  studies  them  carefully,  the  more 
information  will  he  gather  from  them. 

For  the  successful  employment  of  this  new  aid  in  diagnosis, 
the  rontgenologist  should  be  in  possession  of  a  powerful  modern 
equipment.  The  ordinary  type  of  static  machine,  which  can  be 
successfully  used  for  examination  of  the  thinner  parts  of  the 
body,  does  not  furnish  enough  current  to  permit  of  the  examina- 
tion being  made  while  the  patient  is  holding  his  breath.  Some 
of  the  newer  types  of  static  machine  are,  however,  more  efficient 
and  may  be  used  for  this  work. 

If  the  induction  coil  is  used,  it  should  be  capable  of  energizing 
a  high  vacuum  x-ray  tube.  Some  of  the  newer  types  of  trans- 
formers, which  do  not  necessitate  the  use  of  an  interrupter  (as 
does  the  induction  coil),  deliver  a  tremendous  amount  of  elec- 
trical energy,  which  can  be  transformed  in  the  tube  and  produce 
a  plate  in  a  few  seconds.  Given,  however,  a  powerful  generating 
apparatus,  the  next  necessary  part  of  the  equipment  is  a  suitable 
tube.  This  should  be  of  the  size  and  construction  to  permit  of 
its  receiving  and  transforming,  for  a  few  seconds  at  least,  a  very 
large  quantity  of  current. 

In  making  exposures  through  the  thicker  parts  of  the  body, 
as  the  abdomen,  it  is  necessary  that  the  vacuum  of  this  tube 
should  be  high,  in  order  that  the  penetration  may  be  sufficient. 
It  is  obvious  that  if  we  use  a  tube  of  slight  penetration,  such  as 
would  be  useful  in  the  examination  of  the  hand  or  elbow,  that 
we  will  not  be  able  to  pass  the  rays  through  the  body,  and  the 
resulting  plate  will  be  a  comparative  blank.  This  matter  of  the 
selection  of  a  tube  of  high  penetration  is  the  most  important  part 
of  the  Rontgen  teehnic. 

The  size  of  plate  employed  is  usually  14x17  inches.     The  en- 


76  NEPHROCOLOPTOSIS. 

velope  in  which  it  is  contained  can  be  ruled  with  diagonal  cross 
lines,  so  that  the  center  of  the  plate  is  indicated.  The  junction 
of  these  cross  lines  should  be  against  the  umbilicus.  The  position 
of  the  tube  is  of  importance.  In  order  to  avoid  distortion,  the 
central  rays,  or  those  which  are  perpendicular  to  the  long  axis 
of  the  tube,  should  pass  through  the  center  of  the  plate ;  in  other 
words,  the  center  of  the  tube  should  be  opposite  the  center  of 
the  plate,  and  the  plane  of  the  plate  and  the  plane  of  the  tube 
should  be  parallel.  If  the  center  of  the  tube  is  placed  higher, 
for  example,  so  that  it  is  opposite  the  heart,  it  is  evident  that  the 
very  oblique  rays  which  will  strike  the  lower  part  of  the  pelvis 
will  produce  a  great  deal  of  distortion. 

In  the  development  of  the  plate  a  contrasty  developer,  such  as 
hydrochiuon  solution,  with  a  large  amount  of  carbonate  of  potash 
and  an  excess  of  bromide  of  potash,  will  be  of  value.  The  tem- 
perature of  the  developer  is  also  of  importance,  as,  if  the  solution 
is  warm,  the  resulting  plate  will  be  lacking  in  contrast.  The 
purpose  of  the  whole  Rontgen  technic  is  to  produce  a  plate  that 
will  be  free  from  distortion  and  full  of  contrast. 

Differential  Diagnosis. 

The  diseases  having  a  somewhat  similar  symptoma- 
tology to  that  pertaining  to  nephroptosis,  nephrocolo- 
ptosis,  or  coloptosis,  should  be  carefully  considered  and 
the  differentiation  made  in  formulating  the  diagnosis. 

The  most  important  pathological  condition,  and  the 
one  most  likely  to  be  confused  with  the  renal  and  colonic 
displacements  under  consideration,  is  appendicitis.  It  is 
the  most  important  by  reason  of  the  relative  frequency 
of  its  occurrence,  and  also  because  of  the  fact  that  the 
increasing  familiarity  with  its  manifestations  leads  to 
eager  and  often  unwarranted,  incomplete,  and  erroneous 
diagnostic  conclusions.  Pain  and  sensitiveness  alone,  at 
the  McBurney  point,  are  too  often  made  the  basis  of  such 
diagnosis.  A  cecum  and  ascending  colon,  chronically 
distended  by  reason  of  angulation  of  the  large  intestine 


DIAGNOSIS.  77 

anywhere  in  its  course,  will  cause  symptoms  simulating 
subacute  appendiceal  disease;  and  an  acute  distention, 
witli  rapid  dilatation  of  the  cecal  end  of  the  gut,  will  give 
several  local  manifestations  of  such  a  nature  as  to  re- 
quire careful  differentiation.  The  temperature  and  pulse 
record,  if  normal,  in  the  acute  cases,  is  valuable  evidence 
against  the  diagnosis  of  apiDendicitis,  but,  if  a  febrile 
condition  be  present,  further  investigation  is  required,  as 
intestinal  toxemia,  resulting  from  the  colonic  stasis,  may 
be  its  cause.  Absence  of  the  "board-like  feel"  of  that 
side  of  the  abdomen  is  valuable  in  contraindicating  ap- 
j)endiceal  disease,  but  in  the  j)resence  of  great  sensitive- 
ness the  differentiation  may  be  difficult  and  uncertain. 
If  a  radiograph  is  practicable,  the  diagnosis  may  be 
cleared  immediately.  The  radiograph  may  show  a  dis- 
tended cecum,  with  its  distal  end  lying  low  in  the  pelvis, 
indicating  the  j)resence  of  the  appendix  far  from  the 
sensitive  area  around  McBurney's  poiat.  This  would 
indicate  the  cecum  and  ascending  colon  as  the  location  of 
the  manifested  disease,  and  not  the  apjoendix.  A  very 
good  illustration  apropos  of  this  is  seen  in  the  report  of 
case  52.  A  patient  suffering  from  the  acute  symptoms 
of  Dietl's  crisis  of  a  severe  type  may  be  considered  as 
having  appendicitis,  perirenal  al3scess,  or  peritonitis. 
The  history  of  the  attack  and  the  location  of  the  sensitive 
area,  showing,  by  jDalpation,  continuity  of  structure  be- 
tween the  anterior  surface  of  the  swelling  and  the  space 
in  the  loin  just  below  the  twelfth  rib,  point  to  the  en- 
larged kidney  characteristic  of  Dietl's  crisis. 

A  tumor  of  the  right  lobe  of  the  liver  may  simulate  a 
floating  kidney,  and,  if  movable,  may  prove  difficult  of 
differentiation  without  resort  to  exploratory  abdominal 
section.  If  a  malignant  tumor,  the  history  of  progressive 
growth    and    constant    pain,    with   attendant    cachexia. 


78  NEPHROCOLOPTOSIS. 

would  warrant  an  exploratory  section.  Such  a  case  pre- 
sented these  conditions  to  the  author.  Abdominal  sec- 
tion here  revealed  a  neoplasm  springing  from  the  under 
surface  of  the  right  lobe  of  the  liver,  the  free  lower  mar- 
gin of  which  could  be  felt  before  operation,  passing  over 
the  tumor  and  distinct  from  it. 

A  hard  fecal  mass,  resembling  a  tumor,  situated  near 
the  hepatic  flexure  of  the  colon,  may  be  mistaken  for  a 
floating  kidney.  The  free  administration  of  petrolatum 
oil  and  the  use  of  high  enemata  containing  glycerine  and 
epsom  salts  will  usually  clear  the  diagnosis  within  two  or 
three  days. 

A  distended  gall-bladder  may  simulate  a  floating  kid- 
ney. Its  fixed  position  at  a  distance  from  the  loin,  and 
inability  to  elevate  it  into  the  renal  fossa  by  manip- 
ulation, should  render  the  diagnosis  fairly  certain  and 
determine  exploratory  section. 

A  uterine  myoma  having  a  long,  thin  pedicle  may  be 
mistaken  for  a  kidney.  In  such  an  instance  the  free 
mobility  of  the  tumor  downward  compared  with  its  lim- 
ited mobility  upward,  and  the  fact  that  traction  is  felt  to 
be  exerted  on  the  uterus  when  it  is  pushed  forcibly  up- 
ward, should  differentiate  it  from  the  kidney. 

In  severe  cachexia,  which  is  often  present  in  cases  of 
extensive  renal  and  colonic  displacement,  and  frequent 
attacks  of  pain  in  the  epigastric  region,  caused  by  trac- 
tion on  the  duodenum  by  the  dropped  kidney,  may  deter- 
mine a  diagnosis  of  duodenal  ulcer.  Radiographic  ex- 
aminations should  result  in  correcting  the  error. 


CHAPTER  V. 
TREATMENT. 

In  the  selection  of  the  therapeutic  measures  adapted 
to  the  i^athologic  condition  in  question,  the  fact  should 
not  be  lost  sight  of  that  the  symptoms  which  bring  the 
patient  to  the  physician  's  office  are  the  result  of  a 
mechanical  disarrangement  of  certain  organs,  and  that 
consequently  any  treatment  ajoplied  for  the  relief  of  the 
condition  must  of  necessity  be  of  such  a  nature  as  to 
cause  their  rearrangement,  or  rigliting.  Treatment  other 
than  this  is  palliative,  and  not  curative.  And  yet,  for 
the  purpose  of  relieving  symptoms  caused  by  long  con- 
tinuation of  the  displacements,  such  sym]3tomatic  treat- 
ment is  often  necessary  and  of  great  value,  not  only  in 
bringing  comfort  to  the  patient  and  in  the  preparation 
for  curative  treatment,  but  also  as  a  valuable  adjunct  to 
be  used  with  the  more  radical  therapeutics.  While  rare 
cases  do  occur  which  are  completely  and  immediately 
cured  by  operation  alone  (see  case  37),  they  are  by 
far  the  exception  to  the  rule,  as  treatment  by  other 
methods — sometimes  before,  but  usually  after,  operation 
— is  necessary  to  achieve  the  best  results  in  the  shortest 
possible  time.  While  the  author  believes  that  by  surgi- 
cal treatment  the  only  short  route  to  success  is  attained, 
and  that  very  few  cases — possibly  of  recent  occurrence, 
before  colonic  dilatation  has  occurred — can  recover  with- 
out it,  yet  it  must  never  be  depended  upon  alone,  to  the 
exclusion  of  other  therapeutic  measures. 

A  prominent  surgeon  recently  remarked  to  the  author 
after  the  operation  of  nephrocolopexy  and  after-treat- 

79 


80  NEPHEOCOLOPTOSIS. 

inent  liacl  been  described  to  liim:  "I  don't  like  your 
operation  because  you  liave  to  put  on  an  abdominal  band 
afterward.  When  I  operate  I  want  the  operation  to 
cure  and  without  farther  treatment.  I  don't  want  to  see 
the  patients  afterward."  He  was  assured  that  it  was 
largely  that  mental  attitude  of  the  surgeon  that  had  con- 
tinued the  use  of  the  old  unsatisfactory  operation  of 
nephropexy,  but  a  change  of  the  visual  standpoint  must 
now  be  made.  If  these  patients  are  to  be  cured,  the  com- 
plexity of  the  pathology  must  be  recognized  and  all  the 
indications  met.  These  are  not  ''Gordian  knot"  cases, 
to  be  cured  by  one  sweep  of  the  knife,  and  the  sooner  that 
idea  is  understood  the  better,  both  for  the  patient's  wel- 
fare and  for  the  advancement  of  the  medical  art. 

The  successful  operation  merely  places  the  patient  in 
position  for  nature  to  undo  the  damage  done  to  mucosa, 
muscle,  and  nerve  by  the  displacements.  The  repair,  the 
regeneration  of  tired  and  worn  nerves,  the  renewal  of 
muscular  tone,  and  the  restitution  of  long  disordered 
functions  demand  all  the  assistance  possible  until  natural 
conditions  are  assured. 

Treatment  may  be  considered  under  five  heads,  viz.: 
Prophylactic,  Medicinal,  Topical,  Mechanical,  Surgical. 

Prophylactic  Treatment. 

The  consideration  of  the  primary  cause  of  the  ptosis 
is  of  paramount  importance  in  the  selection  of  the  meas- 
ures best  adapted  to  the  prevention  of  the  displacements 
of  the  colon  and  kidney. 

The  child  showing  a  tendency  to  weakness  of  liga- 
ments and  muscular  tissues  should  receive  the  most  care- 
ful attention  duriug  the  whole  of  the  developmental 
period.  Every  effort  should  be  made  to  gradually 
strengthen  the  developing  tissues  of  the  entire  body  in 


TEEATMENT.  81 

such  manner  as  to  cause  symmetrical  growth  of  the  mus- 
cular and  bony  parts,  and  toughness  of  the  restraming 
tissues.  Most  children  of  delicate  physique,  with  heredi- 
tary tendencies  toward  displacements,  lateral  curvature 
of  the  spine,  stoop  shoulders,  prominent  shoulder  blades, 
hernia,  and  other  muscular  or  ligamentous  insufficiency 
may  be  made  to  develop  into  healthy  men  and  women. 
Well-poised,  graceful  bodies  will  result,  chronic  invalid- 
ism will  be  obviated,  and  the  misery  to  themselves  and 
others  from  ill  health  and  awkward  deformity  escaped. 

To  accomplish  this  properly  requires  intelligent  direc- 
tion and  patient  teaching  on  the  part  of  the  doctor,  and 
persistent  application  on  the  part  of  the  patient  and  at- 
tendants for  a  considerable  time.  Gymnastic  exercises 
are  of  the  greatest  benefit,  and  will  accomplish  the  most 
satisfactory  results  in  these  cases,  but  the  exercises  must 
be  carefully  chosen  with  reference  to  the  tendencies  of 
these  patients,  and  they  must  be  so  applied  and  their  in- 
crease so  graduated  that  the  frail  tissues  which  are  to  be 
worked  on  shall  be  raised  in  tone  and  endurance  slowly, 
steadily,  and  surely,  without  depleting  by  overwork  or 
crippling  by  undue  strain.  The  author  has  seen  such 
careful  gymnastic  training,  carried  out  under  the  super- 
vision of  a  competent  orthopedist,  accomplish  really 
wonderful  results  in  the  stimulation  and  development  of 
these  weak  tissues. 

Breathing  exercises  should  be  conducted  in  ways  to 
develop  the  intercostal  muscles  and  diaphragm,  and 
cause  broadening  and  increase  of  capacity  of  the  lower 
part  of  the  thoracic  cavity.  Moderate  work  with  light 
dumb-bells,  exercises  to  develop  the  abdominal  muscles, 
correct  posture  in  standing  and  sitting — all  of  these  in- 
telligently and  persistently  followed  are  of  the  utmost 
value. 


82 


NEPHEOCOLOPTOSIS. 


The  author  has  been  so  much  impressed  with  the  value 
of  well-directed  orthopedic  treatment  in  these  cases  of 
imperfect  development,  that  there  is  here  presented  a 


Fig.  20.  Faulty  standing  pos- 
ture. Chin  forward;  chest  sunk- 
en; shoulders  forward-drooped; 
lumbar  lordosis  decreased;  abdo- 
men prominent;  knees  slightly 
flexed;  feet  everted  and  pronated. 
The  appearance  of  exaggeration  is 
because  persons  in  ordinary  life 
are  clothed,  and  involuntarily  as- 
sume under  observation  an  im- 
proved attitude;  faulty  attitude  is, 
therefore,  commonly  not  seen  at 
its  worst. 


Fig.  21.  Favorable  standing 
posture.  Chin  retracted;  chest  the 
most  prominent  part;  shoulders 
flat  behind;  abdomen  flat;  but- 
tocks prominent;  knees  fully  ex- 
tended;   feet   straight   forward. 


supplemental  and  detailed  article  from  the  viewpoint  of 
the  orthopedist  by  William  E.  Blodgett,  M.  D.,  member 
American  Orthopedic  Association: 


Orthopedic  Considerations  of  Abdominal  Ptosis. 

Faulty  posture  may  be  a  factor  in  causing  or  aggravating  dis- 
placement of  abdominal  viscera,  and,  correspondingly,  favorable 


TREATMENT. 


83 


posture  is  important  in  prophylaxis  and  treatment  of  visceral 
ptosis. 

Faulty  and  favorable  posture  in  standing  and  sitting  are  illus- 
trated by  Figs.  20,  21,  22,  23,  from  photographs  of  a  normal,  well- 
developed  child,  11  years  old.     This  model  is  young  enough  to  be 


Fig-.  22.  Faulty  sitting-  pos- 
ture. Cliin  for-ward  and  upward; 
spine  belo-w  necli  makes  one  long- 
curve,  convex  back-ward;  slioul- 
ders  forward-drooped;  abdomen 
prominent. 


Fig.  23.  Favorable  sitting 
posture.  Chin  retracted;  chest 
prominent;  spine  and  abdomen 
flat. 


free  from  clothing  deformity,  artificial  poses,  and  nervous  con- 
straint, and  old  enough  to  suggest  the  adult  figure. 

There  are  three  chief  ways  in  which  faulty  posture  tends  to 
cause  abdominal  ptosis  :  ( 1 )  by  reduction  of  the  lordosis,  or  for- 
ward convexity  of  the  lumbar  spine,  with  the  attached  soft  parts, 
which,  when  normally  curved,  makes  a  projecting  shelf  in  the 
lower  half  of  the  abdomen ;  ( 2 )  by  relaxing  the  recti  abdominis 
muscles;  (3)  by  the  general  weakness,  of  which  faulty  posture 
is  a  cause  and  a  result.     Faulty  posture  tends  to  reduce  mental 


84  NEPHEOCOLOPTOSIS. 

and  moral  vigor,  and  the  resultant  psychical  depression  reacts 
unfavorably  on  the  physical  health. 

Faulty  posture  may  cause  also  structural  round  shoulders — 
i.  e.,  shoulders  which  can  not  be  placed  in  normal  position — sacro- 
iliac joint  strain  (a  very  common  cause  of  lumbago,  coccygo- 
dynia,  and  sciatica),  and  pronated  painful  feet.  Presence  of 
any  of  these  conditions  assists  in  the  diagnosis  of  habitually 
faulty  posture. 

Treatment  is  chiefly  by  education  and  exercise  in  favorable 
posture.  The  patient  is  first  taught  to  assume  the  favorable  pos- 
ture upon  command,  and  then  to  execute  simple  movements  with- 
out departure  from  this  favorable  posture — movements  such  as 
breathing  and  symmetrical  movements  of  the  arms.  A  long  mir- 
ror in  front  of  the  patient  is  helpful.  Next,  the  patient  is  taught 
to  execute  more  complicated  movements  of  the  whole  body,  always 
starting  from  and  returning  to  the  exactly  favorable  posture. 
In  some  cases  the  chief  need  is  re-education  and  new  co-ordina- 
tion of  the  muscles  to  secure  and  hold  favorable  posture ;  in  oth- 
ers the  muscles  and  ligaments  need  strengthening  as  well.  In 
the  latter  cases,  gradually  increased  weight-lifting  and  dumb-bell 
exercises  are  indicated ;  but  in  all  these  exercises  exactly  correct 
posture  is  to  be  kept  in  mind  and  overexhaustion  avoided.  Spe- 
cial exercises  for  strengthening  the  recti  abdominis  can  be  under- 
taken, such  as  powerfully  retracting  the  abdomen,  and  raising  the 
trunk  from  dorsal  decubitus  to  the  sitting  posture. 

When  pain  interferes  with  normal  posture  of  any  of  the  parts, 
temporary  artificial  support  may  be  needed,  notably  shoulder 
supports,  sacro-iliac  joint  supports  (a  tight  belt  about  the  pelvis, 
just  below  the  anterior  superior  spines),  abdominal  supports, 
spinal  jackets,  and  arch  supports  for  the  soles.  Such  supports 
should  be  made  to  fit  the  individual  patients  and  their  special 
needs;  the  object  of  them  is  to  relieve  pain,  or  assist  in  main- 
tenance of  favorable  posture,  without  interference  with  normal 
function,  until  natural  support  has  become  sui^cient  and  new  co- 
ordinations established.  Passive  resistance  of  the  shoulders  or 
feet  to  being  placed  in  favorable  posture,  or  the  presence  of  any 
interfering  deformity  or  disability,  may  require  surgery. 

In  addition  to  this  education  and  exercise  in  favorable  posture, 
clothing,  outside  air  (especially  at  night),  cold  bathing,  regular 


TEEATMENT.  85 

and  complete  defecation,  and  general  personal  hygiene  are  to  be 
considered.  If  the  clothing  can  not  be  suspended  from  the  hips, 
as  in  young  girls,  the  supporting  shoulder  straps  should  pass 
close  to  the  neck  and  not  over  the  more  easily  depressed  tips  of 
the  shoulders ;  the  corset,  if  worn,  should  be  very  loose  in  its  up- 
per half  and  properly  shaped ;  the  stockings  should  be  supported 
by  straps  from  slightly  in  front  of  the  sides  of  the  corset  and  not 
from  the  front ;  the  shoes  should  have  fairly  straight  inner  bor- 
ders, and  broad,  not  excessively  high,  heels.  These  matters  of 
clothing  and  invigorating  personal  hygiene  are  all  together  an 
important  help  in  the  establishment  of  favorable  posture. 

To  prevent  and  assist  in  the  care  of  abdominal  ptosis,  educa- 
tion and  exercise  in  favorable  posture  must  be  painstaking,  exact, 
and  long  continued. 

Attention  should  be  paid  to  the  diet,  and  each  patient's 
digestive  abilities  and  peculiarities  studied,  so  that  the 
greatest  benefit  may  be  acquired  from  nutrition,  and  also 
that  intestinal  toxemias  do  not  poison  this  fountainhead 
of  supply. 

It  is  of  great  importance  that  these  patients  be  taught 
natural  methods  of  regulating  the  bowels,  and  the  too 
free  use  of  cathartic  medicines  should  be  prohibited. 
Eegular  habits  of  going  to  stool  should  be  advised.  The 
patient  should  go  and  make  the  effort  to  defecate  at  a 
certain  hour  each  day,  preferably  after  breakfast,  even 
if  there  be  no  desire  to  have  a  movement.  Long  habit  of 
neglect  of  regularity  of  the  function  induces  an  obtuse- 
ness  of  the  nerves  of  the  rectum,  which  allows  distention 
and  often  impaction  of  the  viscus,  without  the  patient 
being  aware  of  the  condition  by  an}^  sensation  of  a  desire 
for  defecation.  The  daily  systematic  effort  to  unload 
the  rectum  will  usually  overcome  this  habitual  torpor, 
and  gradually  the  natural  sense  of  rectal  fullness  will  re- 
turn; the  patient  will  know  by  the  sensation  when  the 
bowel  needs  emptying,  and  be  uncomfortable  until  it  is 


86  NEPHROCOLOPTOSIS. 

accomplished,  as  is  the  case  in  the  normal  condition. 
The  patient  should  be  instructed  to  exercise  the  anal  and 
rectal  muscles,  while  attempting  defecation,  by  alter- 
nately raising  and  lowering  the  anus  by  muscular  action. 
The  expulsive  effort  by  the  abdominal  muscles  should 
accompany  the  relaxation,  and,  if  the  patient  sits  with 
the  knees  high  and  thighs  flexed  against  the  abdomen, 
the  expulsive  force  will  be  augmented,  and  be  more 
natural  than  if  sitting  in  the  usual  manner,  with  the 
thighs  at  right  angles  to  the  body,  or  even  somewhat 
dependent.  Abdominal  massage  may  be  used  to  advan- 
tage. 

The  knowledge  that  colonic  stasis,  with  the  consequent 
fecal  accumulation  and  increasing  weight  as  the  bowel 
expands,  acts  mechanically  upon  the  hepatocolic  liga- 
ment,, and  induces  the  beginning  of  the  ptosis  that  gradu- 
ally extends  and  causes  the  complex  pathology  under 
consideration,  should  make  this  question  of  constipation 
— especially  among  the  young — a  very  important  one 
from  a  prophylactic  standpoint.  The  family  physician 
may  use  his  influence  here  to  advantage  in  the  prevention 
of  much  future  suffering.  But,  be  the  patient  young  or 
old,  the  advice  can  not  be  too  strongly  emphasized. 

If  the  kidney  of  a  child  is  displaced  in  any  degree,  an 
abdominal  band  should  be  worn  until  the  formation  of 
a  good  intra-abdominal  pad  of  fat  shall  make  its  use 
unnecessary.  In  those  cases  which  have  a  predisposition 
to  ptosis,  or  in  which  it  has  previously  been  present,  the 
rapid  loss  of  flesh,  from  wasting  disease  or  other  causes, 
removes  the  omental  fat — the  intra-abdominal  pad — 
which  acts  as  a  support  to  the  colon.  The  bowel,  unsup- 
ported, is  then  liable  to  drop,  as  the  weak  hepatocolic 
ligament  gives  way  to  the  unaccustomed  strain.  Such 
cases  should  be  under  careful  supervision,  and  all  tend- 


TREATMENT.  87 

encies  to  colonic  distention  discovered  and  overcome. 
The  same  caution  is  to  be  observed  after  childbirth.  A 
snugly  fitting  abdominal  band  worn  until  the  abdominal 
muscles  regain  their  tone  is  a  valuable  prophylactic  in 
all  post-partum  cases.  Corsets  which  contract  the  lower 
thoracic  zone  should  be  avoided,  and  breathing  exercises 
used  to  expand  this  portion  of  the  anatomy. 

Increase  of  body  fat  is  only  of  mechanical  use,  as  it 
applies  to  tlie  support  of  the  colon  intra-abdominal ly, 
and  for  this  purpose  it  should  be  encouraged  in  every 
way.  Enforced  rest  and  feeding  are  of  value  in  many 
cases  for  this  purpose. 

Medical  Treatment. 

While  the  number  of  drugs  which  can  be  used  with 
direct  benefit  to  the  displaced  colon  and  kidney  is  limited, 
yet  the  conditions  are  such  that,  in  addition  to  them,  in- 
direct medication  is  often  of  value,  and  many  cases  are 
very  materially  benefited  by  the  use  of  other  remedies 
for  the  correction  of  disordered  systemic  conditions 
which  may  appear  not  to  be  directly  associated  with  or 
caused  by  the  ptosis.  The  uric  acid  diathesis,  digestive 
disorders,  inefficient  metabolism,  and  nervous  disorders 
are  pathologic  conditions  which  are  very  common  to 
these  cases,  and  require  appropriate  treatment. 

Cathartics  should  be  avoided  as  much  as  possible,  as 
the  colonic  irritability  is  likely  to  be  greatly  increased  by 
their  use.  The  use  of  eliminatives  which  act  by  increas- 
ing peristalsis,  for  the  purpose  of  accelerating  defeca- 
tion, may  be  compared  to  the  principle  illustrated  by  the 
application  of  an  increase  of  power  to  the  machine  whose 
bearings  require  oil — apparent  immediate  efficiency  re- 
sults, attained,  however,  at  the  expense  of  future  useful- 


«»  NEPHROCOLOPTOSIS. 

ness  of  the  apparatus.  The  action  of  the  bowels  must  be 
regulated  by  remedies  which  smooth  out,  as  it  were,  and 
soothe  the  sharp  angles  of  the  bowel,  and  at  the  same 
time  cause  the  material  to  be  soft  and  easily  moved  for- 
ward by  the  natural  peristalsis.  Nature  endeavors  to  do 
this  by  throwing  out  much  mucus,  which  is  so  frequently 
seen  in  the  stools  of  these  patients. 

Lubricants,  then,  rather  than  cathartics,  must  be  the 
rule,  and,  when  used  intelligently — frequently  by  enema 
as  well  as  by  the  stomach — the  results  are  usually  of  the 
most  gratifying  nature.  For  this  purpose  the  author  has 
found  nothing  else  which  serves  the  purpose  as  satisfac- 
torily in  most  cases  as  the  so-called  ''petrolatum  oil,"  or 
liquid  vaseline.  The  properly  prepared  oil  should  be 
tasteless,  nearly  clear — not  amber  colored — and  should 
be  thick  and  heavy  in  consistency.  The  thin  oil,  which 
is  used  largely  as  a  medium  in  spray  medication,  is  not 
suitable  for  this  purpose.  The  preparation  is,  chem- 
ically, paraffin,  and  not  a  fat,  as  its  name  would  signify, 
and  consequently  does  not  saponify  with  alkalies,  or  be- 
come digested  or  altered  in  passing  through  the  alimen- 
tary tract.  It  is  this  quality  which  causes  it  to  act  in  a 
mechanical  way  only,  passing  through  the  stomach  and 
small  intestines  unchanged,  and  then  into  the  colon, 
where,  b}^  mixing  with  the  fecal  matter  and  coating  the 
mucous  meml)rane,  the  effectiveness  of  peristalsis  is  aug- 
mented; the  contents  of  the  bowel  pass  over  the  angula- 
tions with  a  minimum  amount  of  effort  and  irritation,  to 
the  consequent  comfort  of  the  patient.  The  dose  is  usu- 
ally one  tablespoonful  taken  clear  twice  daily  on  an 
empty  stomach.  The  author  usually  directs  one  dose  to 
be  taken  late  in  the  afternoon,  about  an  hour  before  the 
evening  meal,  and  the  other  at  bedtime.  The  effect  of 
this  oil  is  usuallv  sufficient  to  cause  the  contents  of  the 


TREATMENT.  89 

bowel  to  pass  into  the  descending  colon,  and  in  some 
cases  to  result  in  regular  and  satisfactory  defecation;  but 
the  long  habit  of  irregularity  is  often  not  so  easily  over- 
come, and,  unless  further  assisted,  the  torpid  descending- 
colon  and  the  rectum  do  not  act.  Therefore,  it  is  the  rule 
of  the  author  to  direct  the  patient,  while  taking  the  oil, 
to  use  an  enema  of  normal  salt  solution,  to  overflow, 
every  evening  if  no  satisfactory  defecation  has  been  had 
during  the  day.  After  a  time  the  enema  becomes  un- 
necessary, and  as  the  action  of  the  bowel  becomes  regular 
the  dose  of  the  oil  is  gradually  reduced  and  discontinued. 
Difficulty  is  often  experienced  in  holding  those  patients 
rigidly  to  the  performance  of  this  formulary  who  have 
long  been  addicted  to  the  use  of  cathartic  medicines. 
Any  relapse  occurring  after  the  use  of  the  oil  has  been 
once  discontinued  is  liable  to  be  followed  by  repetition  of 
the  old  habit  of  pill  dosing,  with  consequent  results  of 
colonic  irritability.  To  prevent  this,  patients  who  are 
not  to  be  under  frequent  supervision,  especially  after 
operative  treatment,  should  be  warned  against  the  per- 
niciousness  of  such  action. 

In  cases  of  extreme  torpidity,  especially  those  in  which 
the  fecal  matter  fails  to  reach  the  rectum,  causing  the 
evening  enema  to  be  unsatisfactory  in  results — or,  as  in 
rare  cases,  painful — the  use  by  enema  of  four  ounces  of 
warm  olive  oil  at  bedtime,  the  patient  holding  it  until 
morning,  will  usually  act  very  kindly  in  the  induction  of 
the  desired  morning  stool,  possibly  assisted  by  the 
enema.  Some  patients  find  it  necessary,  in  order  to  re- 
tain the  oil  taken  thus  by  rectum,  to  assume  the  Sims, 
or  knee-chest,  position  for  a  few  minutes  after  its  infec- 
tion. Cases  having  dilatation  of  the  sigmoid  are  much 
benefited  by  the  oil  enema. 

The  author  has  found  a  few  cases  much  improved  by 


90  NEPHEOCOLOPTOSIS. 

the  administration  of  olive  oil  in  gelatin  capsules — three 
to  five  capsules  of  thirty  minims  each  after  each  meal. 
The  oil  given  with  the  gelatin  in  this  manner  seems  to  be 
more  efficacious  than  when  given  alone;  its  nutritive 
value  is  certainly  enhanced,  as  the  stomach  bears  it  bet- 
ter by  this  method.  The  gelatin  doubtless  acts  some- 
what as  a  demulcent,  besides  subdividing  the  oil  and 
rendering  it  more  digestible.  iVs  an  aid  to  any  method 
of  increasing  the  fatty  tissue  of  the  patient  it  is  of  much 
value.  In  some  instances  a  laxative  becomes  necessary, 
and  in  such  cases  castor  oil,  given  in  the  same  manner 
in  gelatin  capsules,  small  doses  after  meals  for  a  day  or 
two,  will  be  sufficiently  effective  and  comparatively  free 
from  irritative  action. 

The  taking  of  two  tablespoonfuls  of  wheat  bran  in  a 
glass  of  hot  water  immediately  on  awakening  in  the 
morning,  and  some  little  time  before  breakfast,  acts  well 
as  a  demulcent,  and  also  mildly  as  a  food  laxative. 
Small  doses  of  bromide  of  sodium  and  chloral  given  in 
chloroform  water  will  be  found  useful,  symptomatically, 
in  soothing  the  colic  caused  by  the  spastic  contraction  of 
the  bowel,  and  may  be  given  in  preference  to  the  opiates, 
which  dry  the  mucous  membranes  and  increase  torpidity 
and  stasis. 

In  cases  having  uric  acid  diathesis  the  spastic  con- 
dition is  frequently  much  improved  by  using  the  appro- 
priate treatment  for  this  condition. 

Intestinal  antiseptics  are  useful  in  combating  the 
toxemia  which  the  sluggish  condition  of  the  colon  fre- 
quently induces.  For  this  purpose  the  author  has  used, 
with  good  results,  the  sulphocarbolates  of  zinc,  calcium, 
and  soda,  carbolic  acid,  menthol,  eucalyptol,  salol,  sali- 
cylic acid  and  the  salicylates,  powdered  charcoal,  aspirin, 
etc. 


TREATMENT.  91 

Physostigmin  sulphate,  gr.  1/100,  given  liypoder- 
mically  every  three  to  six  hours,  has  been  found  to  be  a 
dependable  remedy  for  controlling  the  intestinal  paresis 
which  is  often  such  an  alarming  symptom  in  Dietl's 
crisis. 

Topical  Treatment. 

Heat,  which  may  be  applied  in  various  ways,  is  the 
principal  and  most  reliable  remedy  of  this  class.  Hot 
fomentations,  applied  alone  or  in  combination  with 
spirits  of  camphor,  are  useful  in  alla3dng  the  colonic  irri- 
tability and  relieving  the  general  abdominal  soreness  and 
pain.  The  severe  colicky  pains  caused  by  the  spastic 
condition  of  the  bowel  may  be  treated  with  gratifying- 
results  by  these  applications. 

In  severe  attacks  it  is  sometimes  necessary  to  keep  the 
patient  in  bed,  and  apply  the  heat  almost  constantly  for 
several  days  at  a  time  before  the  pain  and  soreness  are 
overcome. 

Dry  heat  is  the  most  useful  when  the  application  is  to 
be  long  continued.  The  hot  water  bag,  or  hot  plates, 
may  be  used  for  this  purpose,  or  the  electric  pad  may  be 
employed.  The  latter  is  convenient  for  the  continuous 
application,  as  it  is  capable  of  developing  any  tempera- 
ture desired.  It  can  be  left  on  indefinitely,  and  requires 
no  changing  and  reheating  as  does  the  bag  or  fomenta- 
tion. 

The  camphor  stupe  is  especially  useful  in  the  tympan- 
itic condition  of  Dietl's  crisis. 

Mechanical  Treatment. 

Any  treatment  by  mechanical  means  should  be  di- 
rected with  a  view  to  replacing  the  dropped  organs,  and 


92  NEPHEOCOLOPTOSIS. 

to  do  this  understandingiy  the  imderlying  etiologic  fac- 
tors must  be  borue  in  mind. 

The  knowledge  of  the  part  played  by  the  nephrocolic 
ligament  and  Gerota's  capsule  in  x)tosis  of  the  kidney 
exiolains  the  cause  of  failure  of  the  old  method  of  placing 
a  pad  directly  under  the  kidney.  The  same  knowledge 
points  to  a  mechanical  treatment  that  will  be  the  most 
efficient.  The  proj^osition  is  simple  and  purely  mechan- 
ical in  its  nature.  Eemove  from  the  kidney  the  down- 
ward strain  of  the  nephrocolic  ligament,  press  the  intes- 
tines against  it  from  the  direction  of  the  median  line,  so 
that  it  can  not  easily  slip  out  of  Gerota's  capsule,  at  its 
only  oj)en  side,  toward  the  median  line.  The  kidney  will 
then  remain  in  its  normal  position,  the  weight  of  the 
bowel,  and  not  that  of  the  kidney,  being  the  aggressive 
factor. 

This  means  that  a  suitable  apparatus  should  be  worn 
by  the  patient  to  cause  the  cecum  and  transverse  colon 
to  be  held  up  out  of  the  iDelvic  cavity  and  lower  abdomen. 
This  may  be  accomplished  by  the  use  of  bands,  trusses, 
or  corsets,  which  must  be  adapted  to  individual  peculiar- 
ities and  requirements.  A  very  thin  woman,  with  re- 
tracted abdomen,  broad  pelvis,  and  projecting  iliac 
crests,  presents  far  different  requirements  from  one  with 
fat,  protruding  abdomen  and  narrow  pelvis.  The  name 
or  make  of  an  apparatus  is  of  value  only  as  signifying 
a  type,  a  shape,  or  a  principle,  and  becomes  useful  only 
when  it  is  made  to  meet  the  requirements  of  the  in- 
dividual patient.  Perfunctory  band  and  corset  fitting 
by  the  average  artisan  is  liable  to  be  productive  of  much 
harm,  and  tends  to  bring  the  use  of  valuable  therapeutic 
methods  into  disrepute.  The  fitting  of  apparatus  of  this 
kind  is  an  art,  and  should  be  done  by  those  skilled  in  such 
work,  and  with  a  definite  knowledge  of  the  objects  to  be 


TEEATMENT.  93 

attained  by  their  use.  Moreover,  when  the  litting  is  de- 
clared right,  the  patient  should  be  directed  to  report  to 
the  physician  for  inspection.  It  is  only  by  such  pains- 
taking attention  to  details  and  individual  requirements 
that  satisfactory  results  are  achieved.  The  first  requisite 
for  any  appliance  to  be  used  for  this  purpose — such  as 
pads,  trusses,  corsets,  bands,  etc. — is  that  all  j)ressure 
exerted  by  them  should  be  aioplied  to  the  lower  abdomen, 
in  the  space  bounded  above  by  the  navel,  below  by  the 
pubes,  and  laterally  by  the  iliac  crests  and  Poupart's 
ligaments.  With  i^ressure  supporting  the  abdomen  over 
this  area,  and  the  avoidance  of  all  constricting  bands, 
corsets,  or  other  clothing  which  contract  and  lessen  the 
capacity  of  the  abdominal  cavity  above  the  navel,  or  at 
the  lower  thoracic  zone,  the  fundamental  principles  gov- 
erning the  use  of  mechanical  supports  for  the  bowel  and 
kidney  will  be  met. 

The  practical  application  of  these  principles  in  the 
form  of  some  mechanical  contrivance  seems  to  be  largely 
a  matter  of  individual  experience,  as  there  are  in  the 
market  many  varieties  of  trusses,  bands,  and  corsets,  the 
respective  inventors  of  which  extol  their  individual 
merits.  A  corset  specially  adapted  to  support  the  ab- 
domen is,  no  doubt,  practical,  and  can  be  made  to  fulfill 
the  requirements,  but  the  greatest,  and  a  very  potent, 
objection  to  the  use  of  the  corset  is  the  difficulty  of  con- 
trolling its  continuous  proper  application.  There  is  too 
much  variation  in  adjustment,  which  the  patient  may 
control  at  will,  often  causing  the  desire  for  a  good  figure 
on  the  part  of  the  patient  to  frustrate  the  therapeutics  of 
the  doctor.  The  corset  is  also  more  difficult  to  adjust  in 
such  a  way  as  to  give  the  requisite  abdominal  support  in 
cases  having  prominent  hips  and  retracted  abdomen,  and, 
as  these  patients  are  nearly  all  undernourished  and  thin 


94  NEPHROCOLOPTOSIS. 

in  the  beginning  of  treatment,  preference  is  decidedly  in 
favor  of  the  band  or  truss,  to  be  used  until  the  patient 
gains  sufficiently  in  flesh,  when  a  corset  possessing  the 
proper  requirements  may  be  substituted.  For  patients 
whose  iliac  bones  are  not  prominent,  and  those  of  little 
or  no  flatness  of  the  abdomen,  the  author  uses  a  silk 
elastic  band  having  steel  stays  and  leather  re-enforce- 
ment, and  with  a  thick  hair-filled  pad  placed  beneath,  so 
as  to  make  pressure  on  about  half  of  the  lower  abdominal 
space.  The  band  is  held  downward  by  two  perineal 
straps  made  of  heavy  tape,  covered  with  soft  rubber 
tubing,  the  fastening  being  behind  by  an  adjustable  knot 
and  forward  by  a  ball-and-socket  glove  fastener.  The 
band  is  laced  behind  to  fit,  when  the  ends  should  be  about 
an  inch  and  a  half  apart,  to  allow  for  tightening  when 
the  elasticity  decreases.  It  should  be  just  wide  enough 
in  front  to  fill  the  space  between  the  navel  and  pubis, 
which  varies  in  different  individuals  from  five  to  seven 
inches,  and  behind  about  two  and  a  half  inches  less. 
After  it  is  once  fitted,  the  patient  slips  it  on  and  off  over 
the  thighs,  morning  and  night,  without  farther  attention 
to  the  lacing,  which  may  be  left  in  adjustment  until  the 
elasticity  decreases,  or  the  form  of  the  patient  changes, 
demanding  the  alteration. 

The  majority  of  patients,  however,  require  a  sujDport 
so  constructed  as  to  exert  more  pressure  on  the  lower 
abdominal  space,  and  especially  one  which  will  be  made 
efficient  in  this  respect  in  the  class  of  patients  before 
mentioned^ — those  of  meager  habit,  flat  abdomen,  and 
prominent  hips.  Such  a  band  the  author  has  in  the  form 
of  a  combination  of  the  elastic  band  and  truss.  (Fig.  24.) 
The  shape  of  the  band  proper  is  exactly  the  same  as  the 
elastic  band.  It  is  made  of  strong  linen,  with  elastic 
webbing  only  over  the  hips,  laces  together  behind,  and 


TREATMENT. 


95 


is  fitted  the  same  as  the  elastic  band.  The  truss  attach- 
ment is  made  by  the  use  of  a  strip  of  flat  spring  brass, 
which  is  made  to  exert  any  amount  of  pressure  desired 
on  the  center  of  a  hair-filled  pad  placed  beneath  the  band. 
This  spring  is  adjusted  to  the  figure  of  the  patient  by  first 
making  a  pattern  of  soft  sheet  lead,  and  then  bending  the 
spring  to  conform  to  it.  After  the  spring  is  fashioned, 
to  fit,  the  center  is  bent  inward  more  or  less,  according  to 
the  amount  of  pressure  desired  in  each  case.  By  this 
device  the  thinnest  of  patients,  with  prominent  hips  and 


Fig.   24.     Author's  abdominal  supporter. 

flat  abdomen,  can  be  fitted  perfectly,  and  without  the 
discomfort  of  making  a  too  tightly  constricting  band. 
Each  end  of  the  spring  is  turned  back  around  the  hip  and 
ends  in  a  buckle,  by  which  a  strap  of  webbing  passing 
behind  connects  the  two  and  tightens  the  spring.  The 
device  is  light  in  weight,  thin,  and  not  cumbersome  in 
any  way,  so  that  it  can  be  worn  without  disarranging  or 
interfering  with  ordinary  clothing.  The  adjustment  of 
the  band  should  be  such  that  its  grip  will  be  around  the 
circumference  of  the  pelvis,  and  in  no  case  allowed  to 
ride  upward  around  the  waist.   The  perineal  cords,  when 


96 


NEPHEOCOLOPTOSIS. 


properly  adjusted,  should  prevent  this,  and  the  patient 
should  be  instructed  to  see  that  the  upper  margin  of  the 
band  is  on  a  level  with  the  navel.  The  patient  should 
always  wear  the  band  when  not  in  the  recumbent  po- 
sition. It  may  be  slipped  on  and  off  without  unlacing 
in  the  same  manner  as  with  the  elastic  band,  except  for 
the  fastening  and  releasing  of  the  truss.     In  the  daily 


Fig-.  25.  Sliowing  position  assumed  while  massaging  the  abdomen 
previous  to  fastening  tlie  truss  attacliment  of  the  author's  abdominal  sup- 
porter. 

application  of  the  band,  after  it  is  pulled  up  over  the 
thighs  and  adjusted  to  its  proper  position  around  the 
hips,  the  patient  should,  before  buckling  the  truss  fast, 
assume  the  dorsal  position,  with  the  hips  raised  rather 
high — a  modified  Trendelenburg — on  cushions  if  neces- 
sary, and  while  in  this  position  massage  the  abdomen 
deeply  from  the  pubis  upward  with  the  ends  of  the  fin- 
gers of  both  hands   under  the   pad.     (Fig.   25.)     This 


TREATMENT. 


97 


should  be  done  for  several  minutes  for  the  purpose  of 
freeing  the  lower  abdomen,  as  much  as  possible,  of  the 
prolapsed  bowel.  The  truss  is  then  fastened  by  the 
buckles  while  still  assuming  this  position.  The  author 
has  found  this  band  to  be  an  ideal  support  for  the  cases 
in  question,  and  makes  use  of  it  in  many  cases  which 
are  being  prepared  for  operation,  and  in  all  cases,  for 


Fig.    26.     Front   view.     Proper  adjustment   of    the    author's   abdominal 
supporter. 


varying  periods  of  time,  after  operation.  AVhile  this 
supporter  is  the  most  satisfactory  in  filling  all  the  re- 
quirements of  all  others  with  which  he  has  had  experi- 
ence, he  uses  it  only  as  a  valuable  assistant  in  the  cure  of 
these  patients — the  operation  about  to  be  described  being- 
essential  to  permanent  recovery. 

Figs.  26  and  27  show  the  proper  position  of  supporter 
when  adjusted.     Note  the  width  in  front  is  from  navel  to 


98 


NEPHROCOLOPTOSIS. 


pubis,  and  on  the  sides  a  little  less,  so  as  not  to  ride  up 
above  the  liips  and  around  the  waist.  The  truss  is  so 
placed  on  the  sides  between  the  iliac  crests  and  the  groin 
that  it  will  remain  stationary  during  ordinary  move- 
ments of  the  body,  and  will  not  interfere  with  the  flexion 
of  the  thigh. 


Fig-.    27. 
supporter. 


Side    view.     Proper   adjustment    of    the    autlior's    abdominal 


For  temporary  use,  a  pad  may  be  held  in  place  by  ad- 
hesive straps,  which  should  pass  around  the  pelvis,  and 
be  applied  in  such  a  manner  as  to  till  the  requirements  of 
the  band  before  mentioned.  The  iliac  crests  should  be 
protected  from  pressure  hj  thin  pads  of  gauze  or  cotton. 
Ten  days  is  almost  the  limit  of  time  that  such  a  support 
can  be  worn,  as  the  plaster  causes  a  good  deal  of  irrita- 


TREATMENT.  99 

tion  of  the  skin  if  left  much  longer.  This  is  a  useful 
method  of  support,  applied  immediately  after  the  opera- 
tion of  nephrocolopexy,  and  is  applied  in  all  cases  until 
the  band  can  be  worn. 

Operative  Treatment. 

Any  surgical  treatment  of  nephroptosis  which  ignores 
the  accompanying  and  causative  coloptosis  must  fail  as  a 
therapeutic  procedure.  A  moment's  glance  at  the  ana- 
tomic relations  of  the  parts  involved  is  all  that  is  neces- 
sary to  confirm  this  observation.  Strip  the  fatty  capsule 
from  the  kidney,  fasten  the  kidney  to  the  muscles  of  the 
loin  or  other  tissues  in  that  region,  and  what  happens? 
(Fig.  28.)  The  floating  kidney  may  be  cured,  anatom- 
ically speaking,  but  the  patient  is  not,  ais  nearly  all  the 
symptoms,  but  especially  the  digestive  and  nervous  symp- 
toms, not  only  continue  as  before,  but  become  even  more 
aggravated.  This  is  due  to  the  connection  of  duodenum 
and  ascending  colon  by  the  fatty  capsule,  the  framework 
of  which  forms  the  nephrocolic  ligament.  The  result  of 
freeing  the  fatty  capsule  from  the  kidney  is  to  increase 
the  mobility  of  the  ascending  colon  and  cecum,  so  that 
the  traction  exerted  by  the  large  intestine  on  the  duo- 
denum not  only  continues  in  force,  but  is  augmented. 
All  symptoms  would  then  be  aggravated,  excepting  pos- 
sibly those  which  may  have  been  due  to  Dietl's  crisis. 

The  principal  cause  of  the  frequent  failure  of  the  usual 
operation  of  nephropexy  is  thus  explained. 

As  the  first  step  toward  nephroptosis  is  made  by  the 
relaxation  of  the  hepatocolic  ligament  and  the  conse- 
quent increased  mobility  and  dropping  of  the  ascending 
colon  and  cecum,  so  must  the  first  step  toward  a  surgical 
cure  be  either  the  restitution  of  this  support  or  the  crea- 


100 


NEPHROCOLOPTOSIS. 


tion  of  a  substitute  for  it,  which  shall  do  its  work  in  the 
prevention  of  the  downward  drag  of  the  colon  on  kidney 
and  duodenum.     It  seems,  therefore,  that  the  prime  fac- 


Pig-.  2S.  Back  view.  Showing-  the  result  of  cutting-  away  the  fatty 
capsule  from  the  kidney  in  the  old  operation  of  nephropexy.  Increased 
descent  of  cecum  and  traction  on  duodenum  ensues.  (In  confirmation  of 
this  theory  see  Figs.   S7,  88.) 

tor  in  the  surgical  therapeutics  is  fixation  of  the  colon, 
and  that  fixation  of  the  kidney  is  of  secondary  impor- 
tance. 

Before  becoming  convinced  of  this  principle,  and  be- 


TKEATMENT.  101 

fore  realizing  the  surgical  importance  of  the  nephrocolic 
ligament,  the  author  made  several  operations  in  which  it 
was  attempted  to  make  fixation  of  the  bowel  by  fastening 
the  peritoneum  at  the  hepatic  flexure  into  the  wound  in 
the  loin.  It  was  this  work  which  led  to  the  practical 
investigation  of  the  nephrocolic  ligament  in  the  living 
subject,  and  when  the  author  became  convinced  that  it 
had  sufficient  tensile  strength,  when  the  fasciculi  were 
bunched  together,  to  support  the  bowel,  he  abandoned 
the  peritoneal  route  and  developed  the  simpler  and  safer 
method — the  extra-peritoneal  operation — which  he  now 
uses  to  his  great  satisfaction. 

In  a  series  of  fifty-six  operations  the  author  has 
found  only  two  cases  in  which  the  tissue  of  the  ligament 
was  so  distributed  that  its  utilization  was  difficult  and  un- 
satisfactory. In  these  cases  the  network  of  fasciculi,  in- 
stead of  enveloping  the  whole  kidney  and  passing  down 
together  around  the  lower  pole  of  the  organ,  as  usually 
found,  were  placed  on  the  front  side  of  the  kidney  and 
were  spread  out  and  closely  adherent  to  the  peritoneum, 
between  the  kidney  and  colon,  which  caused  the  difficulty 
in  isolating  them. 

The  first  idea  of  the  author,  in  utilizing  the  ligament, 
was  to  cut  it  through  midway  between  the  kidney  and 
bowel,  suture  the  intestinal  portion  into  the  lower  angle 
of  the  wound  and  that  attached  to  the  kidney  into  the 
upper  angle,  but  he  ultimately  adopted  the  present 
method  of  making  a  loop  of  the  ligament  and  slinging  up 
both  bowel  and  kidney  by  suturing  the  tough  tissue  of 
Gerota's  capsule  under  it  and  re-enforcing  this  by  fasten- 
ing the  transversalis  fascia  to  and  under  the  ligament  by 
a  silver  wire  suture.  This  is  the  best  possible  way  of 
securing  the  fixation,  because  its  permanency  does  not 
depend  on  the  adhesion  of  the  ligament  alone  to  adjacent 


102  NEPHROCOLOPTOSIS. 

tissues.  The  imion  of  heterogeneous  tissues,  especially 
when  containing  fat,  is  a  doubtful  process  at  best,  and 
needs  the  assistance  of  all  possible  favoring  conditions, 
which  would  not  be  the  case  if  the  ends  were  simply 
sutured  fast  and  no  other  safeguard  made  against  fail- 
ure. Eeed,  of  Cincinnati,  utilizes  the  nephrocolic  liga- 
ment in  this  manner,  but  he  safeguards  the  suturing  by 
also  fixing  the  kidney  in  the  usual  way. 

Author's  Operation  of  Nephrocolopexy, 

Preparatory  treatment. — In  cases  which  are  recover- 
ing from  Dietl's  crisis  or  extreme  colonic  irritability,  the 
patient  should  be  put  to  bed  and  treated  by  the  methods 
already  described  for  these  conditions,  the  operation  be- 
ing made  only  after  the  complete  subsidence  of  all  acute 
manifestations  and  the  entire  disappearance  of  all  in- 
flammatory perirenal  exudate.  Special  care  should  be 
exercised  in  examinations  of  the  urine,  as  all  evidence  of 
acute  nephritis,  which  frequentl}^  persists  for  some  time 
after  Dietl's  crisis,  must  be  absent.  The  alimentary  tract 
should  be  completely  emptied  the  day  previous  to  opera- 
tion, preferably  by  a  saline  cathartic.  For  this  purpose 
the  author  usually  uses  Seidlitz  powders,  giving  a  double 
powder  every  two  hours,  beginning  before  breakfast,  and 
continuing  their  use  until  five  or  six  satisfactory  stools 
have  resulted.  By  commencing  the  use  of  the  cathartic 
thus  early  in  the  day  the  evacuation  is  complete  before 
night,  giving  the  bowels  time  to  become  quiescent  before 
the  time  of  operation  the  next  morning — which  is  impor- 
tant.    The  diet  during  the  day  should  be  light — soft. 

The  field  of  operation  is  sterilized  in  the  evening,  and  a 
pad  wet  with  sublimate  solution  applied  with  a  binder. 
The  morning   of  the  operation  the  patient   receives  a 


TREATMENT.  103 

simple  enema,  and  immediately  before  going  to  the  oper- 
ating room  a  hypodermic  of  strychnia  sulphate  gr.  1/40.- 

Anesthetic. — Nitrous  oxide  gas,  followed  by  sulphuric 
ether,  unless  otherwise  indicated.  Gastric  lavage  with 
normal  salt  solution  is  used  at  the  conclusion  of  the 
operation. 

Severe  post-operative  vomiting,  which  must  always  be 
a  menace  to  the  success  of  a  recently  fixed  kidney,  is 
practically  a  thing  of  the  past  in  cases  in  which  this  rou- 
tine is  followed. 


Fig.  29.     Author's  kidney  elevator  used  in  tlie  operation  of  neplirocolo- 
pexy. 

Before  the  adoption  of  the  use  of  the  author's  kidney 
elevator,  much  time  was  usually  consumed  in  placing  the 
patient  in  a  satisfactory  position,  owing  to  the  unstable 
condition  of  the  body  of  the  patient  caused  by  the  use  of 
the  inflated  rubber  bag. 

The  author's  kidney  elevator  (Fig.  29)  is  composed  of 
two  i^arts:  (1)  a  round-top  dome  of  nickel-plated  spun 
brass,  having  an  open  base  and  a  round  opening  cut  in 
the  top,  and  (2)  an  ordinary  rubber  ice  cap.  To  prepare 
the  appliance  for  use,  the  rubber  portion  of  the  ice  cap 
is  pushed  through  the  hole  in  the  top  of  the  dome  from 
within,  filled  al)out  lialf  full  of  warm  water,  and  the  stop- 
per screwed  on.  The  flange  onto  which  the  stopper  is 
screwed,  being  larger  than  the  hole  in  the  dome,  holds 


104  NEPHROCOLOPTOSIS. 

the  water  cusliion  well  in  place  on  the  top  of  the  elevator. 
By  the  use  of  this  simple  device,  which  may  be  used  on 
any  kind  of  a  table,  the  patient  may  be  placed  in  position 
without  loss  of  time  by  raising  the  hips  high,  with  the 
patient  lying  face  downward,  and  sliding  the  elevator 
under,  with  the  water  cushion  uppermost.  (Fig.  30.)  As 
the  weight  of  the  patient  is  let  down  on  the  cushion,  it 
being  placed  centrally  under  the  abdomen,  the  abdominal 
contents  are  pushed  upward  and  the  kidney  held  in  po- 
sition. A  pad  or  sand  bag  placed  against  each  thigh 
holds  the  patient  in  exactly  the  position  desired,  which  is 
usually  with  the  side  to  be  operated  on  slightly  the 
higher. 

Before  making  the  incision,  the  reposition  of  the  kid- 
ney should  be  assured  by  examination,  as  a  very  loose 
kidney  in  a  broad  subject  having  a  relaxed  abdominal 
wall  may  not  be  pushed  into  place  by  the  elevator,  and 
may  need  manual  direction  into  the  fossa. 

Instruments  used  in  the  operation  of  nephrocolopexy. 
—  (Fig.  31.)  Scalpel,  1;  scissors,  1;  narrow  retractors, 
2;  hemostatic  forceps,  1;  short  Kocher  forceps,  2;  long 
Kocher  forceps  (made  with  loose  lock  to  avoid  crushing 
tissues),  1;  tissue  forceps,  2;  curved  ligature  carrier,  1; 
bayonet-pointed  side  curved  handled  needle,  1;  full- 
curved  large  Hagadorn  needle,  1;  author's  nephrocolic 
ligament  forceps-hook,  1;  shot  crusher,  1;  suture  ma- 
terial. No.  1  twenty-day  catgut  throughout,  excepting  for 
the  stay  suture  in  the  transversalis  fascia,  where  No.  26 
silver  wire  is  used,  the  twisted  ends  protected  by  a  per- 
forated silver  shot. 

The  seat  of  operation,  having  been  previously  steril- 
ized, is  simply  washed  with  alcohol.     The  incision,  about 


TREATMENT. 


105 


J 


106 


NEPHROCOLOPTOSIS. 


Fig-.   31.     Instruments  used  by  the  author  in  the  operation   of  nephro- 


colopexy. 

1.  Curved  handled  needle,  with 
bayonet  point  and  eye  close  to  it. 

2.  Author's  forceps-hook  for 
securing:  and  forming  a  loop  of  the 
nephrocolic  ligament. 

3.  No.  26  silver  wire  and  per- 
forated silver  shot  for  buried  mat- 
tress suture  of  transversalis  fascia 
(shown  as   applied). 

4.  Bistoury. 

5.  Shot  crusher. 

6.  Long  Kocher  forceps  (with 
loosely  fitting  teeth)  for  finding  the 
nephrocolic  ligament. 


7.  Ligature  carrier  for  passing 
ligatures  under  the  loop  of  liga- 
ment. 

8.  Short  Kocher  forceps  for 
isolating  margins  of  transversalis 
fascia. 

9.  Fine-toothed  tissue  forceps 
for  isolating  margins  of  Gerota's 
capsule. 

10.  Hemostatic   forceps. 

11.  Hagadorn   needle. 

12.  Retractors. 

13.  Scissors. 


TREATMENT.  107 

two  and  a  half  inches  in  length,  is  begun  just  over  the 
lower  margin  of  the  twelfth  rib,  and  at  the  outer  margin 
of  the  quadratus  lumborum  muscle- — which  point  is  a 
little  over  two  inches  from  the  vertebral  spine — and  car- 
ried a  little  diagonally  outward  toward  the  iliac  crest. 
Skin,  fat,  and  superficial  fascia  are  severed,  when  blunt 
dissection  is  used  through  the  latissimus  dorsi  muscle  to 
the  transversalis  fascia,  which  is  grasped  by  two  Kocher 
forceps  and  incised  between;  or  the  fascia  may  be  entered 
also  by  blunt  dissection  by  thrusting  through  and  open- 
ing the  hemostatic  forceps.  The  subperitoneal  (not 
perirenal)  fat  appears.  Eetractors  are  inserted  and  the 
fat  pushed  downward  with  the  finger,  when  Gerota's 
capsule  (perirenal  fascia)  is  seen  at  the  upper  angle  of 
the  wound,  near  the  twelfth  rib,  as  a  pinkish-colored 
membrane,  somewhat  resembling  peritoneum.  This  is 
grasped  with  the  two  fine-toothed  tissue  forceps  and  in- 
cised between,  when  the  perirenal  fat  appears.  If  in- 
cision has  been  made  through  the  transversalis  fascia  too 
far  downward,  and  not  near  the  twelfth  rib,  the  peri- 
toneum (Fig.  13,  No.  10),  and  not  Gerota's  capsule,  will 
be  opened  at  this  stage  of  the  operation.  The  index  fin- 
ger is  inserted  through  the  opening  in  Gerota's  capsule 
(Figs.  32,  33),  and  the  lower  pole  of  the  kidney  located — 
and  it  is  important  that  the  lower  end  of  the  kidney  be 
made  out  definitely,  as  the  nephrocolic  ligament,  if 
grasped  and  fixed  at  the  side  of  the  kidney,  is  secured  in 
but  a  small  part  and  will  have  little  supporting  strength. 
With  the  end  of  the  finger  against  the  lower  pole  of  the 
kidney,  acting  as  a  guide,  the  long  Kocher  forceps  are 
thrust  deep  in  beside  the  finger  and  about  an  inch  below 
the  kidney,  opened  wide,  transversely  to  the  axis  of  the 
kidney,  and  the  tissue  below  the  finger  grasped  by  gently 
closing  the  forceps.     Traction  indicates  to  the  finger  the 


108 


N"EPHROCOLOPTOSIS. 


p,  ft 


o  a 


<1  bX) 


.  O 


TREATMENT. 


109 


110  NEPHEOCOLOPTOSIS. 

success  or  failure  to  locate  the  ligament.  If  properly 
held  by  the  instrument,  the  kidney  may  be  pulled  up 
forcibly  against  the  finger  by  it,  and  the  fasciculi  of  the 
ligament  may  be  felt  to  pass  from  the  forceps  to  the 
kidney.  Several  attempts  may  be  made,  in  some  cases, 
before  the  ligament  is  satisfactorily  secured,  but  it  is 
usually  found  at  once.  Occasionally  the  kidney  lies  low, 
or  in  such  a  position  that  the  examining  finger  can  not 
reach  the  lower  pole,  in  which  case  two  force]DS  may  be 
used,  and  the  kidney  brought  up  by  a  "climbing" 
process,  so  that  the  ligament  below  the  pole  may  be 
reached.  When  secured,  the  kidney  is  pulled  up  to  the 
wound.  (Figs.  34,  35.)  This  spreads  out  the  fasciculi 
of  the  ligament  in  a  fan-shaped  manner,  as  the  inner  side 
of  it  is  adherent  to  the  peritoneum  between  the  kidney 
and  bowel.  To  gather  together  these  separated  fasciculi 
into  one  mass  of  parallel  fibers  is  the  next  step,  which  is 
accomplished  by  means  of  the  forceps-hook.  (Figs.  36, 
37.)  While  the  assistant  holds  the  ligament  gently  taut 
with  the  long  Kocher  forceps,  the  closed  hook  is  passed, 
with  the  finger  as  a  guide,  into  Gerota's  capsule  anterior 
to  the  ligament  and  about  an  inch  below  the  kidney,  and 
pushed  gently  backward  slightly  beyond  the  lower  pole 
of  the  kidney,  the  end  being  held  upward,  so  that  the 
hook  lies  parallel  with  the  kidnej^  After  it  is  placed  in 
this  manner,  the  end  is  turned  toward  the  back  of  the 
patient,  so  as  to  cross  the  back  of  the  ligament  with  the 
hook,  and  then  drawn  upward  toward  the  wound.  The 
finger,  being  removed  at  the  same  time  from  the  anterior 
side  of  the  ligament  and  placed  on  its  posterior  side — still 
within  Gerota's  capsule — guides  the  end  of  the  hook  up 
out  of  the  capsule  and  forces  it  through  the  tissues  cling- 
ing to  it.  Examination  is  then  made,  and  if  a  good  mass 
of  tissue  has  been  secured,  which  pulls  strongly  on  the 


TREATMENT.  Ill 

kidney  and  holds  it  firmly  np  to  the  wound,  the  hook  is 
opened  about  an  inch,  which  strijjs  some  of  the  ligament 
from  the  i^eritoneum  and  forms  a  loop  through  which 
the  fascia  and  capsule  are  to  be  sutured.  (Figs.  38,  39.) 
After  opening  the  forcej)s  once,  they  are  allowed  to  close, 
and  are  opened  only  when  necessary  in  passing  ligatures 
under  and  drawing  the  edges  of  the  capsule  through. 
Some  tough  tissue  is  usually  brought  up  on  the  tip  of  the 
hook,  which  is  the  part  of  Gerota's  capsule  that  passes 
down  with  the  ligament  to  its  insertion  in  the  bowel,  and 
should  be  included  with  the  ligament,  as  it  materially 
strengthens  it.     (Fig.  11.) 

The  next  step  is  the  suturing  of  the  overlapped  mar- 
gins of  Gerota's  capsule  under  the  loop  of  ligament. 
(Figs.  40,  41.)  For  this  purpose  a  mattress  stitch  of  cat- 
gut is  used  on  each  side,  the  first  being  passed  twice 
through  the  free  margin  of  the  capsule  on  the  abdominal 
side,  the  long  ends  brought  through  the  loop  of  ligament 
under  the  hook  with  the  curved  ligature  carrier,  passed 
under  the  capsule  on  the  vertebral  side,  and  with  the 
handled  needle  the  separate  ends  passed  through  the  cap- 
sule and  tied  about  half  an  inch  from  the  margin.  A 
similar  ligature  is  then  made  fast  to  the  margin  of  the 
capsule  on  the  vertebral  side,  the  ends  threaded  through 
the  eyes  in  the  end  of  the  hook  and  the  hook  withdrawn, 
bringing  the  catgut  through  under  the  ligament  with  it, 
when  it  is  passed  through  the  outside  of  the  capsule  on 
the  abdominal  side,  about  half  an  inch  from  the  margin 
of  the  loop  of  ligament,  and  tied  under  the  edge  of  the 
flap.  The  loop  of  ligament  is  still  held  by  the  long 
Kocher  forceps,  which  are  not  removed  till  the  suturing 
around  the  ligament  is  finished. 

The  opening  in  Gerota's  capsule  at  each  end  of  the 
projecting  tissue  of  the  ligament  is  closed  with  ligatures, 


112 


NEPHEOCOLOPTOSIS. 


as 


p-?: 


o  p 

hr,=t-i 


o  o 


-1  ^ 


in-" 


TREATMENT. 


113 


114 


NEPHEOCOLOPTOSIS. 


!i'«>';-,V-''«**^^^~ 


>> 

® 

X 

a> 

ft 

0=H 

o 

o 

o 

<D 

o 

m 

't~t 

3 

ft 

<D 

0) 

m 

>. 

o 

P 

fl 

-u 

o 

a 

d  g 


TREATMENT. 


115 


116 


NEPHROCOLOPTOSIS. 


p,4) 


u  o 

,^3  o 


■55 


5" 


TREATMENT. 


117 


118 


NEPHEOCOLOPTOSIS. 


after  which  the  silver  wire  mattress  suture  is  passed  with 
the  handled  needle  through  the  transversalis  fascia  from 
side  to  side,  broadly,  under  the  loop  of  ligament  and  fas- 


Fig.  40.  Front  view.  Autlioi''s  operation  of  neplirocolopexy,  sliowing 
Gerota's  capsule  overlapped  and  sutured  under  the  loop  of  the  nephrocolic 
lig-ament,  and  the  silver  wire  mattress  suture  passed  through  the  trans- 
versalis fascia  and  under  the  loop  of  ligament. 


tened,  thus  bringing  the  margins  of  the  fascia  under  and 
firmly  against  the  tissue  of  the  ligament.  (Figs.  42,  43.) 
The  wire  is  made  fast  by  twisting  the  ends,  and  a  small 
perforated  silver  shot  run  over  the  ends  down  to  the 


TREATMENT. 


119 


shoulder  and  crushed  with  the  shot-crushing  forceps. 
The  ends  of  the  wire  are  cut  flush  with  the  shot,  which 
leaves  the  suture  in  a  condition  free  from  any  possibility 
of  causing-  irritation  to  the  tissues.  No  post-operative 
trouble  is  had  with  this  buried  suture  made  with  this 
size  of  wire,  protected  by  the  silver  shot.     Farther  clos- 


Latissimus  dorsi 
muscle 


Subperitoneal  fat 


Fig-.   41.      Skeleton  reference  to  Fig.   40. 

ure  of  the  transversalis  fascia  is  made  with  interrupted 
catgut  sutures. 

The  long  Kocher  forceps  are  removed  from  the  liga- 
ment, which  is  now  covered  over  by  the  closure  of  the 
muscle  and  superficial  fascia  by  interrupted  sutures, 
care  being  taken  here — as,  in  fact,  during  the  entire 
operation — to  leave  no  dead  spaces  or  bleeding  points. 
The  operation  is  finished  by  closure  of  the  skin  incision 


120 


NEPHROCOLOPTOSIS. 


(Figs.  44,  45)  with  a  subcutaneous  suture  of  catgut,  which 
is  entirely  buried.  If  the  skin  margins  are  not  exactly 
coapted,  they  are  brought  together  by  narrow  strips  of 
aseptic  adhesive  plaster.     The  scheme  of  the  completed 


Fig-  42  Front  view.  Author's  operation  of  nephrocolopexy,  showing 
the  transversalis  fascia  closed  and  the  method  of  using  the  silver  wire 
mattress  suture. 

operation  is  seen  in  Figs.  46,  47,  and  the  result  of  the  op- 
eration on  the  displaced  kidney  and  compressed  ureter  is 
illustrated  in  Fig.  48. 

The  wound  is  dressed  by  dusting  with  aristol,  covered 


TREATMENT. 


121 


with  a  small  gauze  pad,  which  is  held  and  surrounded 
by  adhesive  plaster,  and  loosely  with  a  large  pad  of 
cotton,  reaching  entirely  across  the  width  of  the  back, 
the  latter  being  held  by  adhesive  plaster  and  a  loosely 
applied  binder.     The  patient  is  then  turned  on  the  back, 


Nephrocolic  lig-ament 


Shotted 

silver  wire  suture 


Retractor 


Latissimus  dorsi 
muscle 


Interrupted  sutures 
of  transversalis  fascia 


Fig.   43.      Skeleton  reference  to  Fig.   42. 

and  the  large  abdominal  pad  applied.  (Fig.  49.)  (See 
Mechanical  Treatment.)  This  pad  should  be  thickest  in 
the  middle,  and  of  sufficient  size  to  fill  the  abdominal 
space  below  the  navel,  and  yet  not  extend  beyond  so  as 
to  cause  pressure  on  ileum  or  pubis.  It  must  be  worn 
constantly  during  convalescence,  and  held  securely  at  all 
times  by  the  adhesive  plaster  and  a  binder  in  addition. 
In  cases  of  severe  post-operative  vomiting  this  pad  is  a 


122 


NEPHROCOLOPTOSIS. 


valuable  safeguard  against  the  threatened  tearing  away 
of  the  newly  sutured  tissues  by  the  violent  muscular 
activity  incident  to  the  einesis;  it  acts  further  as  a  con- 
stant support  to  bowel  and  kidney  during  the  healing 


Fig.  44.  Front  view.  Author's  operation  of  neplirocolopexy,  sliowing 
muscle  and  superficial  fascia  closed  over  loop  of  lig-ament  with  inter- 
rupted sutures  and  the  continuous.,  subcutaneous,  buried  suture  placed 
and  ready  to  draw  tight  and  tie. 

process,  thus  removing  much  of  the  strain  on  the  sutured 
parts. 

After-treatment. — The  patient  remains  quietly  in  bed 
for  from  seventeen  to  twenty  days,  this  length  of  time 


TREATMENT. 


123 


being  considered  necessary  to  insure  the  firm  union  of 
the  mixed  tissues  involved.  The  position  for  right  neph- 
rocolopexy  may  be  dorsal  or  right  lateral,  but  lying  on 
the  left  side  is  strictly  prohibited  during  convalescence. 


'v^ 


Interrupted  sutures.^ 
of  superficial  ^^^ 

aponeurosis  and  muscle .  i 


Skin-., 
Fat 


Pig-.   45.     Skeleton   reference  to  Fig.   44. 

In  the  bilateral  operation  the  dorsal  position  only  should 
be  allowed. 

The  diet  is  of  a  fluid  character  (not  including  milk) 
for  three  days,  then  light  soft  diet  for  seven  days,  and 
mixed  diet  afterward.     The  bowels  are  moved  by  a  low 


124 


NEPHROCOLOPTOSIS. 


Fig.  46.  Author's  operation  of  neplirocolopexy,  sliowing  completed 
operation  and  metliod  by  which  both  bowel  and  kidney  are  supported  by 
fixation  of  the  neplirocolic  ligament  by  the  use  of  Gerota's  capsule  and 
the  transversalis  lascia. 


TREATMENT. 


125 


Superficial  aponeurosis. 


Skin 


12  th   rib-.] 

Overlapped  margins  of 
Qerota's  capsule 

Nephrocolic  ligament 

Interrupted  sutures 
of  transversalis  fascia 

Shotted  silver  wire  -- 
suture  through 

transversalis  fascia-fj 

Continuous 
subcutaneous  suture 

Interrupted  sutures 
of  superficial 
aponeurosis  and 
latissimusdorst 
muscle    -*'-^-.. 


True  perirenal  fat 


-Right  kidney 


-Ileum 


Fig.   4  7.     Skeleton   reference  to  Fij 


46. 


126 


NEPHROCOLOPTOSIS. 


glycerine  enema  (glycerine  gj,  water  gv)  on  the  third 
day,  or  before  if  tympanites  be  tronblesome.  A  low 
enema  of  normal  saline  solution  is  nsed,  to  overflow,  on 
the  evening  of  each  day  thereafter  when  a  satisfactory 
movement  has  not  been  had  during  the  day.  The  admin- 
istration of  petrolatum  oil  (gss),  afternoon  and  bedtime, 
is  begun  on  the  fourth  day  and  continued  until  the  bowels 


Fig-.  48.  A,  position  of  pi'olapsed  kidney,  showing-  compression  of  thft 
ureter.  B,  position  of  tlie  l^idney  -n'hen  replaced  by  flxatioii  of  tlie 
neplirocolic  lig-ament. 

become  regulated  without  the  use  of  the  enema,  when  it 
may  be  gradually  discontinued,  as  indicated.  It  is  some- 
times necessary  to  continue  the  use  of  the  oil  for  some 
time  after  convalescence,  or  to  use  it  from  time  to  time 
as  the  colonic  function  demands. 


TREATMENT. 


12< 


A  mild  saline  laxative  is  often  necessary  on  the  second 
or  third  day  to  clear  up  the  after-effects  of  the  anesthetic, 
when  Husband's  magnesia  (oij),  well  stirred  in  a  glass 
of  water,  will  be  found  useful  and  easy  in  its  action. 
The  glycerine  enema  is  frequently  needed  to  start  the 
movement,  and  may  be  given  if  the  bowels  do  not  act 
within  six  or  seven  hours. 


Fig'.  49.  Showing-  method  of  applying  post-operative  abdominal  pad 
in  the  operation  of  nephrocolopexy.  The  pad  is  held  in  place  by  adhesive 
plaster  and  the  binder  laid  on  ready  to  apply. 


The  wound  is  dressed  on  the  fourth  or  fifth  day  by  re- 
moving dressings,  washing  with  alcohol,  and  reapplying 
the  same  as  before  if  the  condition  of  the  wound  is  good. 
On  the  tenth  day  the  dressings  are  all  removed,  except 
the  large  pad,  which  is  allowed  to  remain  as  a  protection 
to  the  wound  from  injury. 

The  majority  of  these  patients — either  from  the  effects 
of  the  long-continued  toxemia  to  which  they  have  been 
subjected,  or  from  constitutional  causes — exhibit  a  tend- 


128  NEPHEOCOLOPTOSIS. 

ency  to  the  formation  of  uric  acid  and  oxalate  of  lime  in 
the  urine,  and  demand  treatment  accordingly  during  con- 
valescence. For  this  purpose  nothing  has  been  found 
that  equals  in  effectiveness  the  use  of  acid,  nitro-mur. 
dilut.  Mv  in  half  a  glass  of  water  every  three  hours. 

For  several  weeks  after  the  operation  some  patients 
complain  of  discomfort  in  the  region  of  the  ascending 
colon,  caused,  no  doubt,  by  the  unusual  strain  on  the 
nephrocolic  ligament.  This  subsides  in  due  time,  and  no 
harm  ever  eventuates  from.  it. 

Getting  up  and  about  should  be  slow  and  exercise 
taken  gradually,  but  special  care  need  be  observed  only 
against  any  accident  or  overdoing  that  would  cause  sud- 
den or  severe  strain. 

The  abdominal  truss-band,  or  supporter,  is  put  on  when 
the  patient  gets  up,  and  is  worn  thereafter,  when  not  in 
bed,  until  the  accumulation  of  an  intra-abdominal  pad  of 
fat  may  make  its  further  use  unnecessary.  For  a  month 
after  getting  up  the  patient  is  directed  to  wear  at  night  a 
large  abdominal  pad,  applied  with  a  binder. 

The  patient  should  be  under  observation  for  several 
months  after  operation,  as  the  old  bad  habits  of  bowel, 
nerve,  and  muscle  frequently  persist  to  a  certain  extent, 
the  symptoms  not  all  disappearing  at  once.  In  fact,  the 
betterment  comes  gradually,  and  the  patient  must  be  told 
that  this  will  be  so,  and  that  some  period  of  time  must 
elapse  before  great  betterment  can  be  expected. 

In  cases  previously  attended  by  severe  neurasthenia, 
great  tenderness  of  the  abdomen,  gastric  irritation,  etc., 
much  benefit  has  been  derived  by  some  patients  from  a 
course  of  post-operative  sanitarium  treatment,  in  which 
artificial  rest  and  feeding,  freedom  from  care,  abdominal 
fomentations,  and  other  h3^drotherapy  seemed  to  be  the 
principal  restorative  agents.    In  fact,  the  conditions  pre- 


TEEATMENT.  129 

senting  in  most  of  these  patients  demand,  for  their  best 
welfare,  the  utmost  that  they  can  obtain  from  the  sur- 
geon, gastro-enterologist,  neurologist,  psychiatrist,  and 
hygienist.  When  this  principle  is  generally  acted  on, 
and  these  specialists  act  in  harmony — each  doing  his 
very  important  share,  and  giving  to  the  patient  the  best 
in  his  field — then  will  the  greatest  gain  be  made  in  their 
treatment  and  enteroptic  cases  will  cease  to  be  a  re- 
proach to  medicine. 


CHAPTER  VI. 
REPORTS  OF  CASES. 

The  following  reports  of  eases  on  which  I  performed 
my  operation  of  nephrocolopexy  have  been  compiled 
from  the  records  as  concisely  as  possible  consistent  with 
their  intelligent  presentation,  the  aim  being  to  teach  by 
them  the  princijjles  already  laid  down  in  the  text  and 
drawings,  and  to  emphasize  the  im]3ortant  points  of 
pathology,  diagnosis,  and  treatment,  as  well  as  to  record 
results. 

To  accomplish  this  has  necessitated  the  omission  of 
much  of  the  record  of  detail  treatment,  which,  while 
often  of  much  interest  to  the  student  in  showing  the 
process  by  which  the  patient  passes  from  one  form  of 
treatment  to  another,  and  at  last  to  the  surgeon  who 
effects  the  cure,  the  epitomizing  is  demanded  for  brevity 
and  clearness. 

Every  case  has  been  reported,  where  possible,  up  to 
date  of  publication,  and  effort  has  been  made,  by  corre- 
spondence with  patients  and  their  physicians,  to  obtain 
the  histories  of  cases  since  operation,  and  especially  to 
learn  the  permanency  of  results. 

The  first  of  the  series  of  operative  cases  in  which  my 
present  technic  of  nephrocolopexy  is  followed  is  one  of 
the  most  interesting  and  instructive  of  the  entire  number, 
as  the  trials  and  vicissitudes  of  the  enteroptic  suffering 
from  the  results  of  erroneous  diagnoses  and  treatment  are 
most  graphically  illustrated,  and,  as  it  teaches  so  much 
that  may  be  useful  in  the  study  of  the  obscure  diagnostic 
points  in  these  cases,  it  is  presented  rather  fully. 

130 


REPORTS  OF  CASES.  131 


Case  1. 


Female;  aged  26;  small  figure;  thin  habit;  one  child 
1  year  old.  First  consulted  me  in  1900,  complaining 
of  abdominal  pain,  especially  in  the  right  lower  quadrant. 
Tenderness  at  McBnrney's  point  and  an  enlarged  right 
ovary  led  to  an  abdominal  section  and  the  removal  of  a 
nearly  normal  appendix  and  a  cystic  ovary  on  October 
1,  1900,  at  the  Woman's  Hospital.  Recovery  was  un- 
eventful, and  the  patient  went  to  her  home  in  the  in- 
terior of  the  state.  Reports  from  her  continued  to  be 
unsatisfactory,  and  she  returned  to  me  in  May,  1901,  com- 
plaining of  headache,  constipation,  insomnia,  backache, 
occasional  sharp  pains  in  the  right  side  of  the  abdomen 
(as  before  operation),  dyspepsia,  and  loss  of  flesh  and 
strength. 

At  this  time  an  easily  palpable  floating  kidney  on  the 
right  side  was  found,  and  also  a  retroversion  of  the 
uterus  of  second  degree  was  diagnosticated.  An  ab- 
dominal band,  with  a  pad  placed  under  the  loose  kidney, 
was  applied,  and  the  uterus  replaced  and  a  Thomas 
Hodge  pessary  inserted.  The  kidney  pad  and  band 
proved  a  failure  (as  this  one-time-much-recommended 
appliance  always  has  done,  and  always  will  do,  as  the 
idea  of  its  use  is  based  on  erroneous  principles,  as  before 
described  in  this  book).  The  pessary  behaved  better, 
and  afforded  some  comfort  by  changing  it  from  time  to 
time,  the  size  necessary  for  sustaining  the  uterus  in  its 
normal  position  gradually  increasing. 

After  five  years  more  of  semi-invalidism,  resulting,  as  I 
now  know,  principally  from  the  nephrocoloptosis,  she 
again  came  to  me  through  the  courtesy  of  Dr.  I'lorence 
Huson,  at  which  time  the  displacements  of  both  kidney 
and  uterus  were  found  much  more  extreme  and  the  symp- 


132  NEPHROCOLOPTOSIS. 

toms  correspondingly  aggravated.  Previous  to  this  time, 
especially  for  tKe  last  two  years,  she  had  consulted  a 
number  of  physicians  and  experienced  a  variety  of  treat- 
ment, including  two  periods  of  three  months  each  of 
forced  rest  and  feeding.  The  latter  benefited  her  great- 
ly, but  the  improvement  ceased  in  both  instances  as  soon 
as  she  began  to  get  about,  and  soon  afterward  she  was  as 
bad  as  ever.  Previous  to  consulting  Dr.  Huson,  a  repu- 
table surgeon  proposed  to  remove  the  remaining  ovary 
and  make  a  ventrofixation  of  the  uterus. 

At  this  time  I  first  saw  her  with  Dr.  Huson  in  Decem- 
ber, 1905,  at  the  Woman's  Hospital,  where  a  period  of 
three  weeks  of  rest  treatment,  with  hot  fomentations, 
etc.,  was  necessary  to  prepare  her  for  operation  because 
of  the  abdominal  tenderness  and  other  evidences  of  ex- 
treme colonic  irritability. 

On  January  8,  1906,  assisted  by  Dr.  Huson,  the 
operations  of  nephrocolopexy,  Alexander's  operation,  and 
trachelorrhaphy  were  performed.  This  was  the  first 
case  in  which  I  utilized  the  tissue  of  Gerota's  capsule  as 
I  do  now  to  assist  in  fixing  the  nephrocolic  ligament. 

Eecovery  was  uneventful,  and  the  patient  was  dis- 
charged in  about  four  weeks  after  the  operation.  Dr. 
Huson  reports,  November  17,  1909:  ''Patient  very  well 
since  operation  in  1906,  and  has  demanded  treatment 
since  only  for  some  s^nnptoms  of  gastric  indigestion. 
Gave  birth  to  a  child  one  year  ago  at  the  Woman's  Hos- 
pital. Uterus  and  kidney  both  in  normal  position.  Has 
had  no  return  of  the  old  pain  in  the  right  side  since  the 
operation,  and  the  bowels  move  regularly." 

The  relief  of  the  pain  in  the  region  of  McBurney's  point 
was  no  doubt  due  to  the  immobilization  of  the  cecum  and 
ascending  colon,  giving  the  gut  a  fixed  point,  b^^  which  its 
muscular  activities  were  facilitated  and  made  efficient 


REPOKTS  OF  CASES.  133 

in  results.  This  result  following  the  nephrocolopexy  so 
positively,  and  no  benefit  in  this  respect  having  been 
obtained  from  the  previous  operation  of  appendectomy 
and  oophorectomy,  justifies  the  conclusion.  It  also  leads 
to  the  opinion  that  the  appendectomy  was  unnecessary — 
as  my  observation  leads  me  to  believe  is  true  in  similar 
cases  occurring  constantly — and  that  a  riper  experience 
with  the  enteroptic  by  all  concerned  in  her  treatment 
would  have  saved  this  patient  much  distress,  health,  time, 
and  monej^. 

The  following  two  cases  are  of  especial  interest  be- 
cause of  their  family  history  respecting  the  condition  of 
prolapse. 

Case  2. 

Female;  aged  26;  single;  good  figure;  student.  Sister, 
mother,  and  grandmother  had  floating  kidney.  Con- 
sulted me  May  22,  1905,  for  a  nearly  constant,  dull  pain 
in  the  right  side  of  the  abdomen,  which  she  had  had  for 
over  a  year;  fatigue  caused  by  walking;  alternating  con- 
stipation and  diarrhea;  mucus  in  stools;  loss  of  flesh; 
dysmenorrhea.  Examination  in  the  dorsal  position 
showed  the  right  kidney  down  entirely  below  the  costal 
margin.  Applied  elastic  abdominal  band,  with  large 
pad  below  umbilicus. 

June  8,  1905.  Reports  that  she  can  walk  with  much 
less  fatigue  since  wearing  the  band,  and  feels  much  bet- 
ter in  every  way,  excepting  for  the  alternating  constipa- 
tion and  diarrhea,  which  shows  but  little  improvement. 
Intestinal  antiseptics  prescribed  December  20,  1905.  The 
bowel  symptoms  continuing,  and  the  pain  in  the  side  re- 
turn ing  at  times,  operation  was  advised. 

January  13,  1906.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  dilatation  of  os  uteri.  Recovery  un- 
eventful. 


134  NEPHROCOLOPTOSIS. 

November  26,  1906.  Reports  that  the  result  of  the 
operation  has  been  of  the  best;  bowels  regular;  strength 
and  endurance  good;  walked  miles  every  day  during  her 
summer  outing  without  fatigue  or  ill  effect;  gamed  ten 
pounds  in  weight ;  kidney  not  palpable. 

November  10,  1909.  Is  in  good  health,  the  kidney  in 
normal  position,  and  bowels  regular.  While  away  from 
the  city,  two  years  ago,  had  an  attack  of  appendicitis 
and  was  successfully  operated  on  by  another  surgeon. 

Case  3. 

Traumatic  post-operative  displacement  of  kidney,  leav- 
ing" bowel  fixation  intact,  does  not  prevent  symptomatic 
recovery. 

Female;  aged  27;  married;  mother  of  one  child  5 
months  old,  which  is  not  at  the  breast.  Sister,  mother, 
and  grandmother  had  floating  kidney.    (Sister  of  case  2.) 

Diagnosis  of  right  nephroptosis  made  by  me  a  year  be- 
fore marriage,  and  an  abdominal  elastic  band,  with  pad 
below  umbilicus,  prescribed.  Patient  sent  to  me  by  Dr. 
B.  R.  Shurly,  January  26,  1906.  Was  wearing  the  ab- 
dominal belt,  as  she  felt  uncomfortable  without  it.  Com- 
plains of  nervousness;  depression;  pain  in  the  right  side 
of  abdomen;  general  weakness  and  exhaustion  on  slight 
exertion;  backache;  flatulence;  constipation  of  bowels, 
requiring  constant  use  of  laxatives;  hemorrhoids,  which 
bleed  frequently;  leucorrhea. 

Examination  showed  the  right  kidney  entirely  below 
the  costal  margin,  dorsal  position,  without  inspiratory 
efl^ort.  Some  tenderness  at  McBurney's  point  was  ap- 
parently caused  by  a  distended  cecum,  which  could  be 
easily  palpated  through  the  abdominal  walls,  which  were 
thin.     Pelvic  examination  showed  rupture  of  perineum 


EEPORTS  OF  CASES.  135 

of  second  degree  and  a  hemorrhoidal  mass  which  nearly 
encircled  the  anus. 

February  15,  1906.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  perineorrhaphy  by  the  split  flap,  buried 
suture  method;  Whitehead  operation  on  the  anus.  Re- 
covery ideal,  excepting  slight  superficial  stitch  abscess. 
Petrolatum  oil  prescribed.  Abdominal  band  to  be  worn 
until  twenty  pounds  of  flesh  is  gained. 

April  4,  1906.  Condition  good;  gaining  flesh,  and  feels 
well. 

April  14,  1906.  Met  with  an  accident,  having  a  severe 
fall,  after  which  severe  pain  was  felt  in  the  region  of  the 
kidney,  which  was  found  to  be  palpable  and  sensitive  to 
touch.  About  half  of  the  organ  felt  below  the  costal 
margin.  Patient  was  kejot  quiet  in  bed  most  of  the  time 
for  two  weeks,  when  the  tenderness  had  gone  and  only 
the  lower  pole  of  the  kidney  could  be  felt  on  deep  in- 
spiration. 

January  15,  1907.  Kidney  not  loose  enough  to  be  en- 
tirely palpable,  but  lower  pole  easily  felt  on  deep  in- 
spiration.    Bowels  regular  by  use  of  the  oil  only. 

February  1,  1909.  Is  very  well;  bowels  regular  with- 
out medication  and  kidney  gives  no  trouble.  Has  gained 
fifteen  pounds.  The  loosening  of  the  kidney  by  the  acci- 
dent was  probably  due  to  the  fact  that  it  tore  its  way 
through  the  fatty  capsule,  thus  becoming  partially  dis- 
placed only,  and  leaving  the  bowel  fixation  intact;  the 
latter  condition  doubtless  caused  the  marked  subsequent 
improvement  of  the  patient,  and  is  evidence  of  the  cor- 
rectness of  my  theory  regarding  the  role  played  by  the 
displaced  bowel  in  these  cases.  Does  not  wear  the  ab- 
dominal supporter. 

February  2,  1910.  Gained  twenty-one  pounds  since 
operation;  bowels  regular  without  aid  of  any  kind;  per- 


136  NEPHROCOLOPTOSIS. 

fectly  well,  excepting  for  the  presence  of  pain  and  sore- 
ness in  the  right  side,  which  is  of  recent  occurrence  and 
followed  an  attack  of  acute  bronchitis.  Examination  in 
the  dorsal  position  was  negative,  but  in  the  left  lateral 
position  half  of  the  right  kidney  could  be  palpated  and 
was  sensitive  to  touch.  Otherwise  abdomen  not  sensi- 
tive. Abdominal  supporter  to  be  worn  until  relieved  of 
pain  and  sensitiveness. 

Case  4. 

Severe  infection  resulting  from  improper  surroundings 
causes  failure  of  operation. 

Female;  aged  34;  single;  a  teacher  and  convent  resi- 
dent. Had  suffered  for  years  with  pain  in  the  region  of 
the  right  kidney,  apparently  a  mild  Dietl's  crisis;  ab- 
dominal pain;  constipation;  gradual  loss  of  flesh. 

March  10,  1906.  Examination  showed  the  right  kidney 
entirely  below  the  costal  margin  with  patient  in  the 
dorsal  position  and  without  deep  inspiration. 

March  12,  1906.  Operation  of  nephrocolopexy  at  the 
convent,  assisted  by  Dr.  Cadieux,  the  convent  physician. 
The  surroundings  were  not  ideal  for  surgical  work,  and 
every  aseptic  precaution  possible  was  taken,  but  without 
avail,  as  a  very  violent  septic  condition  supervened  and 
the  wound  suppurated  freely,  necessitating  opening  and 
drainage.  I  believe,  even  with  this  suppuration,  the  fix- 
ation would  have  been  successful  if  the  silver  wire  had 
been  used  to  support  the  transversal  is  fascia,  as  it  would 
have  kept  the  parts  in  position  until  the  cessation  of  the 
infective  process  would  have  allowed  the  healing  to  take 
place.  But  the  buried  catgut  was  depended  on  exclu- 
sively, and  of  course  the  natural  result  happened — the 
sutures  gave  way,  allowing  the  parts  to  slip  back  to  their 


EEPORTS  OF  CASES. 


137 


old  positions  of  prolapse,  and  a  failure  had  to  be  re- 
corded. I  wished  to  reoperate,  but  the  opportunity  has 
not  thus  far  presented. 

Case  5. 

Female;  aged  28;  single.  Patient  of  Dr.  G.  E.  Potter, 
who  had  made  the  diagnosis  of  floating  kidney  and  asked 
me  to  operate. 

March  10,  1906.  Examination  showed  the  right  kid- 
ney about  two-thirds  below  the  costal  margin  with  the 
patient  in  the  left  lateral  position  and  during  deep  in- 
spiration. 

March  13,  1906.  Operation  at  Harper  Hospital,  as- 
sisted by  Dr.  Potter.     Recovery  without  incident. 

November  15,  1908.  Dr.  Potter  reports  the  kidney  in 
normal  position;  slight  increase  in  weight;  less  nervous; 
less  pain. 

Case  6. 

Female;  aged  29.  In  the  clinic  of  Dr.  Repp  at  St. 
Mary's  Hospital. 

March  17,  1906.  Operation  at  St.  Mary's  Hospital,  as- 
sisted by  Dr.  Repp.     Recovery  good. 

April  1,  1908.  Dr.  Repp  reports  the  operation  a  suc- 
cess, both  anatomically  and  symptomatically. 

Case  7. 

Type  of  common  class  of  cases,  often  diagnosed  as 
nervous  exhaustion  and  intestinal  dyspepsia,  cured  by 
operation  after  years  of  ''tinkering." 

Female;  aged  31;  mother  of  one  child  7  years  old. 
Cervix  was  lacerated  at  the  time  of  the  birth  of  the 
child,  and  this  was  repaired  by  another  surgeon,  four 
months  before  coming  to  me. 


138  NEPHKOCOLOPTOSIS. 

Patient  sent  to  me  by  Dr.  David  Ingiis,  December  3, 
1903,  to  whom  she  had  gone  for  relief  of  symptoms  of  an 
obscure  nervous  character.  Complains  of  attacks  of 
pain  of  a  bearing-down  character,  which  commence  in 
the  back,  pass  around  in  front  and  down  into  the  vagina 
and  vulva,  causing  great  nervousness  and  frequent  mic- 
turition. Bowels  very  constipated.  Has  lost  flesh  grad- 
ually, about  fifteen  pounds  during  the  last  two  years. 
Heart  normal;  urine  normal. 

Abdominal  examination  showed  the  right  kidney  one- 
half  below  the  costal  margin  while  in  the  dorsal  position. 
Besides  the  slight  nephroptosis,  the  cervix  uteri  was 
found  to  be  cystic,  and  the  cervical  canal  very  narrow 
and  tortuous  (result  of  careless  surgery  in  its  repair). 
Treatment  was  instituted  for  the  latter  condition,  and 
the  position  of  the  kidney  ignored,  as  a  ^'movable"  kid- 
ney was  not  supposed  to  give  symptoms,  and  the  accom- 
panying coloptosis  not  recognized.  Only  slight  relief 
followed  the  treatment,  and  the  patient  passed  from  my 
care  until  January  2,  1906,  when  she  returned,  present- 
ing the  following  history  of  symptoms  and  conditions: 
menstruation  irregular  during  the  last  year,  and  none 
for  nearly  two  months;  diarrhea  more  or  less  for  a  year, 
with  much  mucus  in  stools;  frequent  attacks  of  pain 
in  abdomen,  especially  in  the  right  side;  frequent  mictu- 
rition. 

Abdominal  examination  showed  the  right  kidne}'^  en- 
tirely below  the  costal  margin,  and  in  the  left  lateral 
position  it  could  be  palpated  in  the  region  of  the  navel. 
The  cervix  was  no  longer  cystic,  but  the  os  was  closed 
completely.  The  true  significance  of  the  nephroptosis 
was  now  recognized,  and  a  diagnosis  of  ''nephrocolo- 
ptosis"  made,  with  recommendations  for  immediate 
operation. 


EEPOETS  or  CASES.  139 

June  2,  1906.  Operation  at  Harper  Hospital.  Nephro- 
colopexy;  incision;  dilatation  of  the  os  uteri.  Kecovery 
without  incident.  My  abdominal  band  applied,  and  dis- 
charged from  hospital  June  25,  1906. 

July  11,  1906.  Eeported  feeling  much  better;  frequent 
micturition  ceased.  Lower  pole  of  kidney  felt  below 
costal  margin,  but  could  not  bring  it  lower  by  effort.  Os 
admits  sound  easily. 

October  15,  1906.  Kidney  symptoms  disappeared; 
bowels  regular  and  no  diarrhea;  no  return  of  abdominal 
pain  or  frequent  micturition. 

March  25, 1909.  Reports  she  has  gained  fifteen  pounds 
since  operation;  bowels  are  regular;  feels  well,  excepting 
for  occasional  dyspeptic  symptoms;  kidney  in  normal 
position. 

Case  8. 

Malnutrition  and  intractable  constipation  cured  by 
operation. 

Female;  aged  54;  mother  of  ten  children,  youngest  11 
years  old.  Still  menstruating,  though  irregularly  and 
scantily.  Patient  of  Dr.  F.  L.  Newmann,  sent  to  me  May 
22,  1906.  Complains  of  weakness,  loss  of  flesh,  and  nerv- 
ousness, and  says  her  bowels  are  so  constipated  that  she 
has  an  action  but  once  or  twice  a  week. 

Examination  showed  a  variety  of  pathology,  including 
a  right  nephroptosis — kidney  passing  freely  into  the  ab- 
domen on  deep  inspiration  while  in  the  left  lateral  po- 
sition; large  varicosities  of  left  labium  majus,  thigh,  and 
leg;  ruptured  perineum  of  second  degree;  lateral  lacera- 
tion of  cervix  uteri,  with  cysts  and  erosion.  Recom- 
mended operation  on  all  the  diseased  conditions. 

June  6,  1906.  Operation  at  Harper  Hospital.  Nephro- 
colopexy;   perineorrhaphy;   trachelorrhaphy;   curettage; 


140  NEPHEOCOLOPTOSIS. 

dissection  and  ablation  of  the  varicosities  of  vulva,  thigh, 
and  leg".  Eecovery  was  slow,  owing  to  imperfect  healing 
of  the  incisions  on  the  thigh  and  leg;  otherwise  incisions 
healed  by  first  intention.  Nutrition  had  been  bad  for  so 
long  that  her  strength  returned  slowly.  Petrolatum  oil, 
half  an  ounce  afternoon  and  bedtime,  was  prescribed 
after  the  third  day,  to  be  continued  until  bowels  became 
regular.  My  abdominal  band,  with  large  pad,  was  ap- 
plied before  she  left  the  hos^Dital,  which  was  on  July  4, 
1906. 

October  29, 1906.  Eeports  feeling  better  in  every  way, 
has  more  endurance,  and  bowels  are  regular.  Examina- 
tion shows  kidney  in  good  position;  though  the  lower 
pole  can  be  palpated  on  deep  inspiration,  it  can  not  be 
forced  further  down  and  returns  to  its  normal  position. 

July  1,  1909.  Reports  bowels  regular;  has  gained  ten 
pounds.  Kidney  can  be  felt  half  below  costal  margin 
on  deep  inspiration,  but  causes  no  further  trouble  and  is 
not  sensitive  to  touch.  Has  discarded  the  abdominal 
band. 

Case  9. 

Severe  constipation  cured,  nervous  breakdown  ar- 
rested, and  normal  nutrition  induced  by  operation. 

Female;  aged  27;  single;  stenographer.  Patient  of  Dr. 
E.  S.  Sherrill. 

Examination  June  6,  1906.  Had  severe  anemia  three 
years  ago,  and  dates  present  illness  from  that  time.  Is 
very  nervous  and  debilitated.  Has  lost  flesh  gradually 
for  the  last  two  years,  and  for  the  last  six  months  has 
had,  almost  constantly,  a  dull  pain  in  the  back  of  the 
head  and  neck,  slight  nausea,  but  no  vomiting;  a  feeling 
of  fullness  and  throbbing  across  the  abdomen;  bowels 


EEPORTS  OF  CASES.  141 

very  constipated,  requiring  daily  attention;  menstruation 
very  painful  and  too  frequent. 

Abdominal  examination  showed  the  right  kidney  en- 
tirely below  the  costal  margin  while  in  the  dorsal  po- 
sition without  effort;  was  easily  replaced  manually,  and 
quite  sensitive  to  touch.  Vaginal  examination  negative, 
excepting  showing  endometritis.    Operation  advised. 

July  6,  1906.  Operation  at  Harper  Hospital.  Nephro- 
colopexy;  dilatation;  curettage.  Recovery  without  inci- 
dent. 

July  23.  Discharged  from  hospital,  wearing  abdomi- 
nal band  and  taking  petrolatum  oil. 

September  24,  1906.  Reports  first  menstruation  pain- 
less, and  second  somewhat  painful  and  scanty.  Bowels 
perfectly  regular  since  operation.  Has  had  some  pains 
in  cecal  region,  apparently  due  to  distention  with  gas  (a 
common  symptom  for  several  weeks  after  this  operation, 
which  passes  away  when  the  bowel  regains  its  tone). 
Examination  showed  the  lower  pole  of  the  kidney  pal- 
pable, but  it  could  not  be  brought  farther  below  the 
costal  margin. 

November  21,  1906.  Feels  very  well;  menstruation 
painless;  bowels  continue  regular;  has  gained  ten  and 
one-half  pounds  since  the  operation.  Has  taken  off  band, 
and  since  doing  so  notices  some  return  of  the  pain  in  the 
cecum.     Advised  reapplication  of  the  band. 

December  28,  1909.  Dr.  Sherrill  reports  the  patient 
in  good  condition  in  every  way;  weighs  one  hundred  and 
twenty-two  pounds  (a  gain  of  about  twelve  jDounds  since 
operation) ;  has  no  symptoms,  as  before  operation,  con- 
nected with  the  kidney,  which  retains  its  normal  po- 
sition; bowels  slightly  constipated. 


142  NEPHEOCOLOPTOSIS. 

Case  10. 

A  case  for  the  neurologist. 

Female;  aged  29;  married  three  years;  never  pregnant. 
Patient  of  Dr.  Jones,  of  Pittsford,  Mich. 

September  15,  1906.  Examined  at  St.  Mary's  Hospital. 
Was  wearing  an  adhesive  plaster  abdominal  band,  which 
patient  said  had  been  applied  two  weeks  before  by  a 
gastro-enterologist  for  floating  kidney.  The  band  had 
not  benefited  her,  and  was  causing  a  good  deal  of  irrita- 
tion of  the  skin,  as  is  usual  with  adhesive  plaster  when 
left  on  longer  than  a  week  or  ten  days.  Has  had  daily 
attacks  of  severe  nausea  and  emesis,  attended  with  great 
nervous  disturbance,  for  over  a  year,  and  dates  the  begin- 
niQg  of  the  symptoms  from  an  attack  of  acute  nephritis, 
from  which  she  completely  recovered.  Six  months  ago 
had  the  uterus  and  adnexa  removed  by  a  surgeon  in  the 
interior  of  the  state,  but  with  no  benefit. 

Abdominal  examination  showed  right  nephroptosis  of 
moderate  degree  in  left  lateral  position,  and  a  sensitive 
area  in  the  epigastrium.  Urine  normal.  Operation  was 
advised,  although  the  neurotic  element  in  the  case  made 
the  outcome  problematic,  and  the  husband  was  so  in- 
formed, with  the  understanding  that  an  exploratory  ab- 
dominal section  should  be  made  to  determine  the  con- 
dition of  the  pylorus  and  gall-bladder. 

September  19, 1906.  Operation  of  nephrocolopexy  and 
ex23loratory  abdominal  section  (negative  result)  at  St. 
Mary's  Hospital  before  the  class  of  the  Detroit  Post- 
Graduate  Medical  School.  Recovery  was  uneventful,  and' 
for  the  following  two  weeks  the  pain,  nausea,  and  other 
symptoms  were  decidedly  better.  After  this  time  they 
began  to  gradually  recur,  nausea  occurring  very  early  in 


EEPOETS  OF  CASES.  143 

the  morning;  these  attacks  gradually  increased  in  sever- 
ity after  leaving  the  hospital. 

May  24,  1907.  Patient  reported  in  person.  The  kid- 
ney was  in  normal  position,  and  the  bowels  regular,  but 
all  other  symptoms  were  much  worse,  and,  as  the  neu- 
rotic element  now  seemed  to  be  most  decidedly  the  domi- 
nant factor,  I  sent  her  to  my  friend.  Dr.  David  Inglis, 
who  reports  that  he  treated  the  patient  from  June  11, 
1907,  to  September  9,  1907;  that  treatment  at  first  was 
based  on  the  supposition  that  a  uric  acid  diathesis  was 
the  causative  factor  in  the  pathology,  but  later  concluded 
the  attacks  were  purely  hysteric  in  origin,  and  advised 
certain  disciplinary  measures.  An  abstract  from  a  let- 
ter written  by  'her  husband  in  December,  1907,  gives  a 
very  encouraging  report  of  the  results  of  the  last  advised 
form  of  treatment. 

Case  11. 

The  following  is  the  case  on  which  the  original  obser- 
vation was  made  that  led  to  the  discovery  of  the  nephro- 
colic  ligament.  It  is  also  my  first  case  of  operation  for 
the  relief  of  symptoms  caused  by  coloptosis  alone,  with- 
out nephroptosis.  Obstinate  constipation  completely 
cured. 

Female,  aged  16;  single.  Patient  of  Dr.  Hugh  Gary, 
of  Delray,  Mich. 

December  10,  1903.  Saw  patient  in  consultation  with 
Dr.  Gary,  when  she  complained  of  a  pain,  often  of  a  grij)- 
ing  character,  in  the  right  side  of  the  abdomen,  which 
she  had  had  for  about  a  year.  During  this  time  she  had 
gradually  lost  flesh,  and  the  bowels  had  become  more 
and  more  constipated.  Menstrual  history  normal.  Ex- 
amination was  negative,  excepting  for  a  marked  tender- 
ness  on   pressure   at   McBumey's  point.     The   kidneys 


144  NEPHEOCOLOPTOSIS. 

were  carefully  examined  for  ptosis,  with  negative  results. 
The  sensitive  area  at  McBnrney's  iDoint  and  the  history 
of  the  pain  in  the  same  region  led  to  the  diagnosis  of 
aiDj)endiceal  disease  of  some  kind — probably  adhesions — 
and  appendectomy  was  advised. 

December  17,  1903.  The  operation  of  appendectomy 
was  made  at  Solvay  Hospital,  when  the  organ  was  found 
bound  by  adhesions  to  the  cecum  in  sharp  angulation. 
As  the  cecum  was  found  in  the  bottom  of  the  pelvis — 
and,  as  a  matter  of  course,  the  appendix  with  it — I 
marveled  at  the  time  at  the  pain  and  tenderness  at  Mc- 
Burney  's  point  previously  experienced  by  the  patient.  I 
know  now  that  the  |)ain  was  not  in  the  appendix  at  all, 
but  was  in  the  cecum  and  ascending  colon,  and  was  due 
to  the  coloptosis.  It  was  during  this  operation  that  I 
discovered  that  the  right  kidney  could  be  pulled  down 
by  making  traction  on  the  cecum,  as  described  on  pages 
9,  10.  The  patient  made  a  good  recovery,  and  was  dis- 
charged from  the  hospital  with  expectation  of  complete 
relief.  But  this  result  did  not  occur,  as  the  pain  not  only 
continued  the  same,  but  the  constipation  became  so  bad 
as  to  cause  almost  an  intestinal  obstruction  at  times,  re- 
quiring more  and  more  evacuants,  and,  when  these  failed, 
larger  and  larger  enemas  to  cause  the  discharge  of  the 
fecal  contents  of  the  colon.  This  condition  was  some- 
what relieved  by  the  use  of  an  abdominal  supporter,  but 
the  constipation  continued  as  bad  as  ever,  so  that,  with 
my  later  acquired  knowledge  of  the  action  of  the  pro- 
lapsed colon  and  the  utility  of  the  newly  discovered 
nephrocolic  ligament,  I  advised  the  operation  of  nephro- 
colopexy  for  the  sole  purpose  of  relieving  the  torpidity 
of  the  bowel.  At  this  time  the  patient  complained  of 
frequent  sick  headaches,  had  become  very  thin,  her  com- 
plexion was  sallow,  skin  rough  and  pimply,  and  expres- 


REPORTS  OF  CASES.  145 

sion  apathetic,  besides  complaining  of  severe  dysmenor- 
rliea  for  six  months. 

September  28,  1906.  At  the  Solvay  Hospital,  Delray, 
I  performed  the  operation  of  nephrocolopexy  and  dilated 
the  cervix  uteri,  and  removed  a  small  mucous  polyp  from 
the  endometrium.     Recovery  was  ideal  in  every  way. 

October  7,  1907.  Reports  bowels  perfectly  regular 
without  medication,  and  have  been  so  since  the  operation 
of  over  a  year  ago.     Has  gained  fifteen  pounds. 

October  17,  1908.  Bowels  regular.  Feels  well,  except- 
ing for  occasional  pain  in  the  cecum,  apparently  due  to 
gas. 

Case  12. 

Case  of  "chronic  diarrhea" — a  neurasthenic  invalid 
— cured  by  nephrocolopexy.  A  gain  of  twenty-two 
pounds  in  weight. 

Female;  aged  42;  married;  no  children.  Patient  of 
Dr.  R.  W.  Alton,  of  Portland,  Mich. 

For  several  years  had  suffered  with  neurasthenia; 
daily  abdominal  pains;  alternating  constijoation  and 
diarrhea,  with  much  mucus  in  stools;  flatulence;  occa- 
sional attacks  of  pain  and  tenderness  in  the  right  side  of 
the  abdomen;  during  the  last  two  years  lost  a  great  deal 
in  weight  and  became  very  nervous,  and  is  in  conse- 
quence a  chronic  invalid;  exceedingl}^  thin;  weighs  nine- 
ty-four pounds. 

October  4,  190G.  Examination  in  the  dorsal  decubitus 
showed  the  right  kidney  entirely  prolapsed  without 
bringing  it  down  b}^  the  inspiratory  effort.  It  was  easily 
replaced  manually,  and  remained  in  normal  position 
while  the  patient  was  recumbent,  but  immediately 
dropped  out  of  jDlace  on  assuming  the  erect  position. 

October    5,    1906.     Operation    of    nephrocolopexy    at 


146  NEPHEOCOLOPTOSIS. 

Harper  Hospital.  Eecovery  ideal.  Patient  in  iDed  two 
weeks.  Abdominal  supporter  applied  and  petrolatum 
oil  prescribed.    Discharged  October  30,  1906. 

December  7,  1909.  Dr.  Alton,  in  answer  to  my  request 
for  a  report  on  this  case,  sends  me  a  long  letter  from  tlie 
jDatient,  dated  Idaho  Falls,  Idaho,  December  1,  1909, 
from  which  I  make  the  following  quotations:  ^'Yes,  I 
am  sure  the  kidney  is  in  place.  I  still  have  to  use  enemas 
occasionally,  but  the  bowels  are  so  much  better  than  be- 
fore the  operation  that  I  am  sure  they  will  get  entirely 
well.  When  we  left  for  the  West  I  weighed  one  hundred 
and  four  pounds  (a  gain  of  ten  pounds),  and  I  now 
weigh  over  one  hundred  and  sixteen  pounds  (total  gain 
of  twenty-two  pounds),  and  am  in  horror  of  growing  old 
and  fat!  My  general  health  is  certainly  much  better, 
and  you  can  judge  about  my  endurance  when  I  tell  you 
I  am  doing  all  the  hard  work  for  a  family  of  six,  and  on 
a  ranch  at  that,  and  I  get  nervous  only  when  I  get  over- 
tired. I  am  so  much  better  than  before  my  operation 
that  I  hardly  know  myself." 

Case  13. 

Perfect  anatomic  result  of  operation.  Case  having 
persistent  uric  acid  diathesis  and  severe  neurasthenia. 

Female;  aged  32;  married;  mother  of  three  children, 
the  youngest  2  years  old.  Patient  of  Dr.  F.  W.  Mann,  of 
Detroit,  Mich.  Her  history  was  exceedingly  stormy  and 
eventful  from  a  pathologic  and  operative  standpoint,  and 
presented  a  doubtful  proposition  for  the  further  exploita- 
tion of  surgery.  She  had  had  about  a  dozen  operations, 
including  four  for  tubercular  glands,  two  for  repair  of 
lacerations  incident  to  parturition,  several  for  hemor- 
rhoids, and  one  for  post-partum  infection. 


REPORTS  OF  CASES.  147 

August  30,  1906.  Gave  the  following  history  in  ad- 
dition to  the  alcove:  lost  a  good  deal  of  weight  during 
the  last  year;  very  nervous  and  despondent;  nearly  con- 
stant i^ain  in  )3ack  of  hips  and  right  side  of  abdomen,  the 
latter  tender  to  touch;  frequent  attacks  of  severe  pain, 
attended  with  nausea  and  retching,  without  vomiting, 
requiring  hypodermics  of  morphia  to  relieve;  bowels 
very  constipated,  requiring  constant  attention;  menstrua- 
tion too  frequent,  is  frequently  clotted  and  often  lasts  ten 
to  fourteen  days.  Was  in  bed  six  weeks  a  year  ago  for 
neurasthenia. 

External  examination  showed  general  abdominal  ten- 
derness, which  was  especially  acute  on  the  right  side  in 
the  region  of  McBurney's  point;  the  right  kidney  was  en- 
tirely below  the  costal  margin  without  effort;  freely 
movable  and  easily  replaced,  although  sensitive  to  touch. 

Pelvic  examination  showed  a  laceration  of  the  cervix 
uteri  on  the  right  side;  uterus  and  cervix  large  and 
hyperplastic;  adnexa  normal  and  organs  in  normal  po- 
sition. 

Urine,  specitic  gravity,  1.028;  acid  reaction;  highly  col- 
ored; slightly  turbid.  No  albumin  or  sugar.  Micro- 
scopic examination  showed  a  few  leucocytes,  squamous 
epithelium,  and  large  crystals  of  uric  acid. 

A  diagnosis  was  made  of  nephrocoloptosis,  laceration 
of  cervix,  and  endometritis,  and  operation  advised.  The 
character  of  the  attacks  of  pain  in  the  region  of  the 
pylorus  and  gall  ducts,  as  I  had  not  seen  the  patient  in 
one,  were  something  of  a  problem,  but,  as  the  tenderness 
was  in  the  kidney  and  not  in  the  region  indicated,  I 
concluded  the  attacks  were  probably  due  to  some  form  of 
Dietl's  crisis,  or  were  produced  by  a  sharp  kink  in  the 
common  bile  duct  arising  from  the  traction  of  the  kidney 
on  the  duodenum.     (Figs.  4,  6.) 


148  ,  NEPHROCOLOPTOSIS. 

October  18, 1906.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  trachelorrhaphy;  curettage.  The  wounds 
healed  perfectly.  Patient  was  kept  in  bed  eighteen 
days,  and  made  an  unexpectedly  smooth  recovery  while 
in  bed,  but  convalescence,  after  being  up  a  few  days,  be- 
gan to  be  stormy,  and  continued  so  for  about  six  weeks, 
the  symptoms  being  of  a  nervous  and  dietetic  character, 
and  apparently  due  to  faulty  metabolism.  The  urine 
during  this  time  was  usually  of  low  specific  gravity,  con- 
taining free  urates  and  occasionally  uric  acid  crystals. 
An  occasional  attack  of  the  old  epigastric  pain  was 
averted  each  time  by  a  hypodermic  of  hyoscin  liydro- 
bromate  gr,  1/200,  as  were  also  other  attacks  of  a  purely 
hysteric  character.  She  was  discharged  from  the  hos- 
pital November  10,  1906,  but  did  not  leave  her  room  at 
home  until  December  30,  1906.  After  this  time  a  muscu- 
lar rheumatism  of  the  right  side  and  shoulder  developed, 
which  was  successfully  treated  at  a  sanitarium. 

April  29,  1907.  Patient  reported  in  person.  Gained 
some  in  flesh,  digestion  improved,  bowels  regular  (takes 
the  oil) ;  has  had  but  two  slight  attacks  of  the  epigastric 
pain  in  four  months.  The  kidney  was  in  normal  position, 
only  the  lower  pole  being  palpable  on  deep  inspiration  in 
left  lateral  position. 

Have  not  been  able  to  see  this  patient  since  the  last 
date,  as  she  lives  at  a  distance.  She  writes  that  she  has 
not  gained  much  in  flesh,  and  that  her  nervous  symptoms 
are  still  in  evidence. 

The  case  is  apparently  one  which  demands  constant 
supervision  of  diet  and  general  habits  of  life  to  combat 
the  effects  of  the  uric  acid  diathesis,  which  seems  to  be 
the  basic  element  m  the  present  pathology. 


EEPOETS  OF  CASES.  149 


Case  14. 


Perfect  anatomic  and  symptomatic  results  of  operation. 
Apparent  wounding  of  cortex  of  kidney,  resulting  in  pro- 
fuse leakage.    Perfect  recovery. 

Female;  aged  40;  married;  one  child  8  years  old.  Ab- 
dominal section  and  bilateral  salpingo-oophorectomy  for 
hydrosalpinx  and  cystic  ovaries  by  me  in  1900. 

September  10,  1906.  Has  had  abdominal  pains  of  a 
griping  character  for  over  a  year,  mostly  in  right  side; 
lost  weight  steadily  for  two  years;  bowels  very  consti- 
pated, and  movements  often  attended  with  abdominal 
pains;  is  nervous  and  sleeps  badly;  menstruates  regu- 
larly and  normally;  has  some  leucorrhea. 

Examination  in  the  dorsal  decubitus  showed  general 
abdominal  tenderness,  and  right  kidney  entirely  below 
the  costal  margin  and  freely  movable.  Vaginal  exami- 
nation showed  a  cystic  cervix  and  hyperplastic  uterus. 
Applied  abdominal  band,  and  prescribed  petrolatum  oil 
—one  tablespoonful  afternoon  and  bedtime,  and  warm 
olive  oil — three  ounces  by  rectum  at  bedtime;  scarified 
cervix. 

October  8,  1906.  No  improvement.  Advised  fixing 
the  colon  and  kidney,  and  curetting  the  uterus. 

October  20,  1906.  Operation  at  Harper  Hospital. 
Nephroeolopexy;  curettage.  Buried  sutures  used  of 
twenty-day  catgut  only.  The  external  continuous  suture 
of  silkwormgut  was  removed  on  the  sixth  day  (October 
26),  when  union  was  good  and  wound  appeared  normal, 
and  a  normal  recovery  indicated,  with  no  pain  or  rise  of 
temperature. 

October  31.  Pain  in  the  scar,  which  was  found  to  be 
distended  and  bulging,  and,  on  incision,  quite  a  quantity 
of  thin,  clear,  odorless  fluid  spurted  out.     A  drainage 


150  NEPHROCOLOPTOSIS. 

tube  was  inserted,  and  this  clear  fluid  dripiDed  constantly 
from  it  to  the  extent  of  from  thirty  to  forty  ounces  daily. 
A  specimen  was  sent  to  the  Detroit  Clinical  Laboratory 
on  November  3,  and  the  following  report  made:  ''This 
fluid  is  almost  colorless,  with  a  slight  yellow  tinge,  is 
cloudy,  neutral  in  reaction,  and  has  a  specific  gravity  of 
1,003.  The  fluid  gives  a  test  with  sodium  hypobromate 
for  urea,  the  urameter  showing  0.3  percent.  Micro- 
scopically numerous  leucocytes  are  seen.  "While  it  can 
not  be  positively  stated  that  the  fluid  consists  only  of 
urine,  the  evidence  points  to  the  presence  of  urine  in  it." 

At  the  time  this  fluid  first  appeared,  the  patient 's  tem- 
perature was  100.5°,  but  subsided  to  normal  shortly  after 
the  evacuation,  and  remained  so  during  her  further  con- 
valescence. The  wound  closed  closely  around  the  rub- 
ber drainage  tube,  allowing  of  little  leakage,  so  that  the 
daily  quantity  was  readily  collected  and  measured,  which 
amounted  to  from  thirty  to  forty  ounces.  This  decreased 
gradually  until  January  14,  1907,  when  she  left  the  hos- 
pital in  good  condition,  with  the  wound  closed  and  re- 
tracted. 

January  25.  The  scar  was  found  slightly  bulging,  and 
was  incised,  letting  out  about  an  ounce  of  clear,  odorless 
fluid.  After  this  the  scar  remained  closed  and  retracted, 
and  gave  no  further  trouble.  During  the  time  of  the 
discharge  of  the  fluid,  and  since  its  cessation,  the  kidney 
gave  no  symptoms. 

March  21,  1909.  Patient  reports  that  she  is  enjoying 
good  health;  that  the  bowels  are  regular,  requiring  occa- 
sionally-— for  a  week  or  so  at  a  time — the  use  of  the 
petrolatum  oil;  the  abdominal  pains  have  disappeared; 
she  has  gained  twenty  pounds  in  weight.  Kidney  is  in 
normal  'position. 


EEPOETS  OF  CASES. 


151 


Case  15. 

Case  having  Dietl's  crisis;  obstinate  constipation  and 
malnutrition  cured  by  operation. 

Female;  aged  42;  single;  saleswoman.  Patient  of  Dr. 
R.  E.  Loueks. 

March  23,  1907.  Saw  her  in  consultation.  Has  had 
griping  pains  in  abdomen  for  several  years;  lost  weight 
steadily  for  three  years;  bowels  very  constipated,  re- 
quiring much   medication,    and   movements   filled   with 


Fig.   50.     Case  1.5. 


mucus;  had  attack  of  severe  pain  and  swelling  in  right 
side  of  abdomen  and  loin  three  weeks  before,  which  con- 
fined her  in  bed  for  two  weeks;  menstruation  normal. 

Examination  showed  a  very  tender  and  somewhat  en- 
larged right  kidney,  entirely  below  the  costal  margin; 
also  much  sensitiveness  over  entire  right  side  of  ab- 
domen. 

Vaginal  examination  showed  normal  introitus;  small 
cervix  pointing  forward;  fundus  fixed  in  retroversion  of 
third  degree;  two  small  nodules  anteriorly  and  to  right 


152  NEPHROCOLOPTOSIS. 

on  fundus,  all  fixed  and  immovable,  and  very  sensitive; 
heart  normal;  urine  normal. 

April  1,  1907.  A  radiograpli  (Fig.  50)  showed  the 
cecum  lying  in  the  bottom  of  the  pelvis,  with  its  lower 
end  in  the  region  of  the  bladder  and  uterus,  the  first  half 
of  the  transverse  colon  lying  across  the  pelvis  nearly  in 
juxtaposition  with  it,  and  the  second  half  in  a  vertical 
position,  lying  close  to  the  left  parietes,  and  apparently 
directly  in  front  of  the  descending  colon.  This  position 
of  the  second  section  of  the  transverse  colon  would  neces- 
sitate the  formation  of  a  very  acute  angle  at  its  junction 
with  the  descending  colon  at  the  splenic  flexure — similar 
to  a  rubber  tube  hung  over  a  peg — and  at  a  glance 
showed  the  difficulty  the  bowel  must  labor  under  in  forc- 
ing material  from  the  transverse  colon  over  this  angle 
into  the  descending  colon.  The  suggestiveness  of  this 
point  revealed  by  this,  my  first  successful  radiograph  of 
the  colon,  was  immecliateh"  apparent  as  an  index  to  much 
of  the  sjTuptomatology  in  not  only  this  case,  but  in  others 
of  a  similar  nature. 

The  acute  irritation  of  the  kidney  having  subsided, 
operation  was  advised  on  both  the  kidney  and  the  pelvic 
organs. 

April  3,  1907.  Operation  at  Harper  Hospital.  Nephro- 
colopexy;  abdominal  section,  with  enucleation  of  two 
walnut-size  fibroids  from  the  uterus;  breaking  up  ad- 
hesions; appendectomy,  the  organ  being  adherent  to  the 
parietal  peritoneum  in  front  of  the  bladder;  Alexander's 
operation  by  the  blunt  hook  method.     (Kellogg.) 

Recovery  good  and  afebrile;  in  bed  sixteen  days;  had 
pleuritic  pains  in  right  side,  lasting  three  days,  during 
the  middle  of  convalescence.  Abdominal  supporter  ap- 
plied and  petrolatum  oil  prescribed  on  discharge  from 
the  hospital. 


EEPOKTS  OF  CASES.  153 

September  24,  1907.  Gained  ten  pounds  and  looks 
well;  bowels  still  need  tlie  oil,  and  occasionally  the  even- 
ing enema;  some  soreness  in  the  kidney,  the  lower  pole 
of  which  can  be  palpated  below  the  costal  margin  on  deep 
inspiration.     Olive  oil  per  rectnm  prescribed. 

From  this  time  on  for  a  year  gained  constantly  in  flesh 
and  looked  well,  bnt  complained  more  or  less  of  soreness 
in  the  region  of  the  cecum  and  kidney,  and  a  pulling  sen- 
sation in  the  round  ligament  fixations. 

May  3,  1909.  Kidney  in  good  condition,  gives  no 
trouble  in  any  way,  and  is  free  from  sensitiveness. 
Bowels  in  better  condition,  but  require  the  use  of  the 
petrolatum  oil,  and  the  olive  oil  per  rectum  occasionally. 
Had  pneumonia  six  months  ago,  and  since  recovery  from 
that  has  gained  flesh  and  is  now  back  to  normal  weight. 

Case  16. 

A  case  of  nephroptosis,  with  unrecognized  coloptosis, 
of  long  standing. 

Female;  aged  41;  married;  mother  of  one  child,  now 
25  years  old.  Patient  of  Dr.  Sidney  I.  Small,  of  Saginaw, 
Mich.  Saw  her  first  April  23,  1903,  when  she  gave  the 
following  history:  menstruation  normal;  bowels  very 
constipated  for  years,  and  lately  movements  attended 
with  abdominal  pain  and  much  mucus  seen  in  the  stools; 
pain  in  back  and  hips  for  six  months,  and  for  years  has 
had  pain  at  times  in  the  left  side  of  the  upper  abdomen; 
fatigues  easily  and  can  walk  but  little;  riding  ''jars," 
and  causes  abdominal  pain  and  headache.  Had  opera- 
tion for  lacerations  incident  to  parturition  seventeen 
years  ago,  and  had  an  attack  of  "inflammation  of  the 
bowels"  a  year  afterward.  Has  had  no  return  of  the  in- 
flammatory trouble  since.  Pulse  and  temperature  normal. 


154  NEPHROCOLOPTOSIS. 

Abdominal  examination  in  the  dorsal  decubitus  showed 
the  right  kidney  entirely  below  the  costal  margin  with- 
out effort,  and  a  fullness  and  sensitiveness  over  the  en- 
tire left  side.  Pelvic  examination  showed  a  normal 
perineum;  large  cystic  cervix,  lacerated  on  the  right  side; 
uterus  normal. 

Diagnosis  showed  floating  kidney,  lacerated  cystic 
cervix,  and  colonic  catarrh  (the  fact  that  coloptosis  is 
always  present  with  nephroptosis  not  then  known  to  me). 
A  silk  elastic  abdominal  band,  with  pad,  below  the  navel 
was  applied,  flushing  of  the  colon  with  normal  salt  solu- 
tion prescribed,  and  the  cervix  scarified.  This  treatment 
was  continued  until  June  24,  1903,  when  the  operation 
of  trachelorrhaphy  and  curettage  was  done  at  the 
patient's  residence.  Recovery  from  this  was  slow, 
though  the  cervix  healed  well  and  there  were  no  local 
symptoms.  Patient's  nutrition  continued  inadequate; 
she  lost  weight  gradually,  and  became  nervous  and  de- 
spondent; the  bowel  symptoms  continued  as  before. 
Various  kinds  of  treatment,  by  myself  and  others,  were 
used,  with  no  satisfactory  results  until  April  2,  1907, 
when  I  was  called  to  see  her  in  consultation  with  Dr. 
F.  E.  McClure,  who  had  treated  her  for  some  weeks  with- 
out benefit.  I  found  her  confined  to  bed  and  suffering 
with  the  old  colonic  symptoms  intensified,  and  also  from 
severe  attacks  of  pain  in  the  pelvis  and  back.  She  was 
in  a  state  of  extreme  neurasthenia,  could  take  little  nour- 
ishment because  of  gastric  irritability,  and  had  frequent 
attacks  of  tachycardia. 

Examination  showed  the  nephroptosis  as  before,  but  a 
change  had  taken  place  in  the  pelvic  organs,  the  fundus 
uteri  being  nodular  and  a  cystic  tumor  present  on  each 
side  of  it. 

After  trying  some  other  forms  of  treatment,  a  further 


EEPORTS  OF  CASES.  155 

consultation  was  held,  Dr.  C.  G.  Jennings  at  this  time 
assisting  in  the  disposition  of  the  trying  case.  Notwith- 
standing her  enfeebled  condition,  operation  was  decided 
on,  and  the  family  so  advised. 

April  16,  1907.  Operation  at  Harper  Hospital,  as- 
sisted by  Dr.  McClnre.  Nephrocolopexy;  abdominal  sec- 
tion; myomectomy  of  one  small  fibroid;  double  sal]3ingo- 
oophorectomy  (hydrosalpinx  and  cystic  ovaries) ;  appen- 
dectomy. Both  wounds  healed  perfectly  and  there  were 
no  unusual  temperature  conditions,  but  the  convalescence 
was  stormy  in  the  extreme  because  of  the  persistent 
atony  of  the  bowels  and  the  enfeebled  condition  of  the 
patient.  These  conditions  were,  however,  successfully 
met  and  the  patient  was  out  of  danger  in  ten  days  after 
the  operation.  In  bed  three  weeks.  Owing  to  s5"mptoms 
of  a  nervous  character,  due  largely  to  the  menopause, 
precipitated  to  some  extent  by  the  operation,  the  con- 
valescence, after  leaving  the  hospital,  was  slow. 

June  10,  1907.  Has  gained  ten  pounds;  bowels  regular 
by  the  use  of  the  oil;  passages  contain  no  more  mucus; 
still  has  some  colonic  pain,  which  is  steadily  diminishing ; 
appetite  and  digestion  about  normal.  Examination 
shows  kidney  in  normal  position. 

July  2,  1908.  Has  gained  eighteen  pounds;  bowels 
regular  by  occasional  use  of  the  oil;  no  more  mucus;  only 
occasional  abdominal  pain. 

Case  17. 

Nephrocoloptosis,  complicated  by  infective  chole- 
lithiasis. 

Female;  aged  56;  widow;  three  children,  the  youngest 
22  years  old.     Patient  of  Dr.  E.  E.  Loucks. 

May  12,  1907.     Saw  her  in  consultation,  when  she  gave 


156  NEPHKOCOLOPTOSIS. 

a  history  of  numerous  attacks  of  gallstone  colic,  consti- 
pation, loss  of  flesh,  and  neurasthenia.  Menopause 
passed  for  several  years.  Suffering  with  pain  in  the  epi- 
gastrium and  right  side,  close  under  the  costal  margin. 

Examination  showed  great  sensitiveness  and  fullness 
in  the  region  of  the  gall-bladder  and  between  Mc- 
Burney's  point  and  the  costal  margin,  and  without 
effort  a  loose  right  kidney  completely  below  the  costal 
margin.  Heart  normal,  100;  temperature  100.5°.  A  diag- 
nosis of  biliary  calculus  in  the  cystic  duct  and  nephro- 
coloptosis  was  made,  and  operation  advised.  Examina- 
tion of  the  urine  on  the  following  day  showed  it  to  be 
normal. 

May  14,  1907.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  cholecystotomy ;  removal  of  stones;  drain- 
age. Drainage  tube  removed  on  tenth  day.  Recovery 
without  incident.  In  bed  sixteen  days.  Abdominal  band 
applied  and  petrolatum  oil  prescribed,  and  patient  dis- 
charged June  8,  1907. 

December  7,  1909.  Dr.  Loucks  reports  no  pain  in  the 
region  of  the  kidney,  which  is  in  normal  position;  nutri- 
tion very  much  improved,  as  shown  by  a  large  increase  in 
weight — about  twenty  pounds. 

Case  18. 

Colonic  symptoms   completely  cured  by  operation. 

Female  (colored);  aged  26;  married;  no  children;  clin- 
ical patient.     Had  complete  hysterectomy  in  1905. 

May  14,  1907.  Gave  the  following  history:  has  had 
pains  in  the  abdomen,  of  a  griping  character,  for  over  a 
year;  has  lost  flesh  considerably,  but  does  not  know  how 
much;  bowels  very  constipated,  and  takes  all  sorts  of 
medicines  to  act  on  them;  sleeps  badly,  and  is  so  weak 


EEPOETS  OF  CASES.  157 

that  she  is  unable  to  do  work.  Examination  in  dorsal 
decubitus  showed  the  right  kidney  only  slightly  (lower 
half)  below  the  costal  margin,  but  on  putting  her  in  the 
left  lateral  position,  with  deep  inspiration,  the  whole 
kidney  could  be  palpated  in  the  region  of  the  navel. 

May  17,  1907.  Radiograph  showed  the  cecum  and  first 
half  of  the  transverse  colon  in  the  pelvis. 

May  18,  1907.  Operation  at  Harper  Hospital.  Right 
nephrocolopexy.  The  wound  healed  perfectly,  and  re- 
covery was  normal  and  afebrile  until  the  eleventh  day, 
when  pain  in  the  left  groin  was  comj^lained  of  and  a  mild 
phlebitis  developed,  which  subsided  in  ten  days  without 
leaving  any  untoward  result.  Because  of  that  the  pa- 
tient was  kept  in  bed  for  twenty-five  days. 

June  24,  1907.  Discharged,  wearing  an  elastic  abdomi- 
nal band  and  taking  the  petrolatum  oil. 

June  12,  1908.  Patient  reported  at  the  office.  Bowels 
regular;  no  more  al)dominal  pain.  Examination  showed 
kidney  .in  normal  position.     Has  gained  eight  pounds. 

Case  19. 

Neurasthenia  and  malnutrition.  Gain  of  twenty-six 
pounds  after  operation. 

Female;  aged  41;  single;  seamstress.  Patient  of  Dr. 
R.  E.  Loucks. 

May  17, 1907.  Seeks  relief  for  backache;  monorrhagia; 
leucorrhea;  pain  in  the  right  side  of  abdomen;  neuras- 
thenia; loss  of  flesh;  dyspepsia.  Menstruation  is  irregu- 
lar, and  often  is  of  ten  days'  duration.  All  symptoms 
of  three  years'  standing,  and  commenced  with  an  attack 
of  nervous  prostration,  lasting  several  months.  Weighs 
one  hundred  and  fourteen  pounds;  looks  thin  and  anemic, 
and  badly  nourished. 


158  NEPHEOCOLOPTOSIS. 

Abdominal  examination  in  the  dorsal  decubitus  showed 
the  right  kidney  entirely  below  the  costal  margin, 
brought  down  by  deep  inspiratory  act,  and  readily  re- 
placed manually. 

Pelvic  examination  showed  a  retroverted  uterus  of 
second  degree,  which  was  apparently  deviated  backward 
by  a  walnut-sized  myoma  situated  anteriorly  just  above 
the  bladder. 

Diagnosis  made  of  nephrocoloptosis,  uterine  subserous 
myoma,  and  granular  endometritis.  Operation  recom- 
mended. 

May  20,  1907.  Operation  at  Harper  Hospital.  Right 
nephrocolopexy;  curettage;  abdominal  section;  myomec- 
tomy. Recovery  without  incident.  Left  the  hospital 
wearing  the  abdominal  band,  but  not  taking  the  petro- 
latum oil,  as  the  bowels  were  regular. 

October  8,  1907.  Gained  twelve  pounds;  no  backache 
or  pain  in  abdomen  and  side;  has  menstruated  but  once 
in  the  three  months,  and  that  very  little.  Examination 
in  left  lateral  position  shows  lower  pole  of  kidney  pal- 
pable below  costal  margin,  but  can  be  brought  no  further 
down. 

October  2,  1908.  A¥eighs  one  hundred  and  forty 
pounds,  has  good  endurance  and  nerve  tone,  and  feels 
well. 

July  27,  1909.  Says  she  has  had  no  pain  in  side,  ab- 
domen, or  back  since  operation.  Weighs  one  hundred 
and  thirty-five  pounds.  Examination  in  dorsal  decubitus 
shows  kidney  in  normal  position;  left  lateral  decubitus 
allows  palpation  of  lower  pole  below  costal  margin. 

Case  20. 
A  case  in  which  probable  mutilative  surgery   could 
have  been  avoided  if  the  surgeon  had  had  a  knowledge 


EEPOKTS  OP  CASES.  159 

of    colonic    pathology.     Completely    cured   by   nephro- 
colopexy. 

Female;  aged  28;  single;  teacher.  Had  left  ovary  re- 
moved in  1900  to  cure  a  pain  in  the  left  side  of  the  ab- 
domen, and  two  years  after  had  the  appendix  and  right 
ovary  removed  for  pain  in  the  right  side  of  the  abdomen. 
Both  operations  by  other  surgeons. 

December  15,  1904.  Seeks  relief  for  the  same  ab- 
dominal pain  as  she  had  previous  to  the  operations  two 
and  four  years  ago.  Still  menstruates,  though  irregu- 
larly and  painfully;  has  backache  and  headache  con- 
stantly; is  steadily  losing  weight  and  strength;  is  consti- 
pated; sleeps  badly;  says  she  has  had  to  give  up  her 
position  as  teacher  because  of  increasing  exhaustion  and 
nervousness.  Temperature  and  pulse  normal.  Urine 
normal,  excepting  for  amorphous  urates. 

Abdominal  examination  in  the  dorsal  position  showed 
a  very  sensitive  area  at  and  around  McBurney's  point, 
but  no  descent  of  the  kidneys.  The  left  lateral  position 
was  therefore  tried,  with  the  result  of  bringing  the  right 
kidney  down  and  imprisoning  it  below  the  costal  margin 
with  the  hands.  The  left  kidney  could  not  be  palpated 
in  either  position. 

Vaginal  examination  showed  a  small,  movable  uterus 
in  second  degree  of  retroversion — otherwise  negative. 
Urine,  pale  color;  specific  gravity,  1,012;  acid;  no  albu- 
min or  sugar;  slightly  turbid  with  urates. 

A  diagnosis  of  nephrocoloptosis  was  made,  and  a  silk 
elastic  abdominal  band,  with  abdominal  pad,  applied. 
Various  forms  of  internal  medication,  electrical  treat- 
ment, massage,  etc.,  were  used  by  myself  and  several 
other  physicians  during  the  following  two  and  a  half 
years,  but  without  benefit,  the  patient  constantly  losing 


160  NEPHROCOLOPTOSIS. 

flesh  and  sliowing  continnally  worse  conditions  of  the 
nutritive  functions. 

May  29,  1907.  Patient  returned  to  me,  complaining  of 
attacks  of  severe  pain  in  the  region  of  the  right  kidney, 
lasting  about  a  week  at  a  time;  irregular,  painful,  and 
often  very  free  and  clotted  menstruation;  leucorrhea; 
constipation.     Operation  advised. 

May  29,  1907.  Operation  at  Grace  Hospital.  Nephro- 
coloi^exy;  dilatation;  curettage  of  uterus.  Eecovery 
without  incident.  Abdominal  supporter,  with  the  truss 
attachment,  applied  and  petrolatum  oil  prescribed  on 
discharge  from  the  hospital. 

Gradual  improvement  ensued  for  the  first  six  months, 
with  only  some  nervous  symptoms,  and  the  patient  was 
lost  sight  of  until  July  14,  1909,  when  she  reported  in 
person.  Had  gained  fifteen  pounds  since  ojDeration; 
bowels  regular  without  medication;  nervous  system  and 
general  endurance  about  normal.  Had  not  worn  the  ab- 
dominal supporter  for  several  months,  and,  as  she  had 
occasionally  a  "bearing  down"  in  the  abdomen  when 
fatigued,  a  new  supporter  was  advised.  Kidney  in 
normal  position. 

Case  21. 

Nephrocoloptosis  and  hematocystic  ovaries.  Anatomic 
and  symptomatic  recovery. 

Female;  aged  31;  single.  Patient  of  Dr.  D.  H.  Burley, 
of  Almont,  Mich. 

June  7,  1907.  Seeks  relief  for  monorrhagia,  pain  in 
lower  abdomen  and  thighs,  constipation,  frequent  and 
painful  micturition,  leucorrhea,  indigestion,  occasional 
attacks  of  griping  pain  in  abdomen.  Says  she  sleeps  well 
if  lying  on  the  right  side,  but  badly  on  the  left  side  owing 
to  palpitation  of  the  heart  while  in  the  latter  position 


EEPORTS  OF  CASES.  161 

(common  symptom  in  right  neplirocoloptosis).  Heart 
normal,  80;  temperature,  98°.  Urine,  acid;  contained 
nothing  abnormal,  excepting  amorphous  urates. 

Examination  in  dorsal  decubitus  showed  a  flat  ab- 
domen, with  thin  walls.  Abdominal  sensitiveness  gen- 
eral; right  kidney  entirely  below  costal  margin.  Pelvic 
examination  showed  a  retroverted  uterus,  loosely  fixed 
by  adhesions;  two  large,  apparently  cystic,  ovaries,  the 
right  being  adherent  to  the  uterus  and  cul-de-sac.  Diag- 
nosis of  neplirocoloptosis,  cystic  ovaries,  adhesions,  uter- 
ine retroversion,  and  endometritis.    Operation  advised. 

June  21,  1907.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy,  curettage,  abdominal  section; bilateral  oopho- 
rectomy; breaking  up  adhesions.  Both  ovaries  large  and 
polyhematocystic.  Recovery  without  incident.  Abdomi- 
nal band  applied  and  petrolatum  oil  prescribed,  and 
patient  discharged  July  18,  1907. 

September  21,  1907.  Bowels  regular;  still  uses  the 
petrolatum  oil,  but  requires  no  enema.  Has  some  back- 
ache, apparentl}^  caused  by  low  position  and  some  retro- 
version of  the  uterus.  Says  she  can  now  sleep  on  the 
left  side  without  discomfort,  and  micturition  is  normal. 
Examination  showed  kidney  in  normal  position. 

July  11,  1908.  Patient's  condition  good,  and  has 
gained  considerably  in  weight.  Has  had  extract,  ovarii 
for  "hot  flushes"  and  some  remedies  for  indigestion,  but 
otherwise  has  needed  no  treatment.  Still  wears  the  ab- 
dominal band  and  takes  the  oil  occasionally. 

Case  22. 

Perfect  restoration  of  floating  kidney  by  nephro- 
colopexy. 

Female;  aged  36;  married;  mother  of*  one  child  6 
months  old.     Not  nursing  the  child. 


162  NEPHKOCOLOPTOSIS. 

January  18,  1907.  Seeks  relief  for  pain  and  ''bearing 
down"  in  rectum  and  vagina,  and  pain  in  the  right  side 
of  the  abdomen.  Has  had  the  pain  in  right  side  of  ab- 
domen for  several  years,  but  dates  the  pelvic  symptoms 
from  the  birth  of  the  child,  which  was  instrumental,  and 
from  which  slow  recovery  was  made.  Has  not  menstru- 
ated since,  and  is  very  anemic  and  debilitated. 

Examination  in  dorsal  decubitus  was  negative,  but  in 
the  left  lateral  position  the  right  kidney  dropped  entire- 
ly below  the  costal  margin  and  could  be  palpated  at  the 
navel. 

Pelvic  examination  showed  a  ruptured  perineum  of 
the  third  degree  and  a  badly  lacerated  cervix — poste- 
riorly and  right  laterally.     Operation  advised. 

June  24,  1907.  Operation  at  Woman's  Hospital. 
Nephrocolopexy,  trachelorrhaphy;  perineorrhaphy.  The 
perineal  tissue  was  very  scanty,  cicatricial,  and  retracted; 
the  parts  were  coapted  with  some  difficulty  by  the  split- 
flap,  buried  suture  method.  The  wounds  healed  per- 
fectly, excepting  that  of  the  perineum,  which  suppurated 
slightly,  but  it  eventually  closed  so  as  to  give  a  fairly 
good  result  and  a  very  good  sphincter  ani. 

Owing  to  her  debility,  convalescence  was  slow,  and  she 
was  discharged  from  the  hospital  August  4,  1907,  wear- 
ing the  abdominal  band,  but  not  using  the  oil,  as  the 
bowels  were  regular. 

October  4,  1907.  Kidney  in  perfect  position.  Says 
that  she  has  no  more  pain  in  that  side. 

September  1,  1908.     Pregnant  seven  months. 

May  4,  1909.  At  confinement,  four  months  ago,  had 
retained  placenta  and  resultant  sapremia,  requiring 
curettage.  Examination  showed  a  cystocele.  Kidney  in 
normal  position. 


REPORTS  OF  CASES.  163 

Case  23. 

Case  illustrating  the  common  occurrence  of  the  mis- 
take of  making  the  operation  of  appendectomy  for  symp- 
toms produced  by  nephroptosis. 

Female;  aged  23;  single;  teacher.  Patient  of  Dr. 
^^ernier. 

June  21,  1907.  Seeks  relief  for  pain  and  distention  in 
right  side  of  abdomen;  sensation  of  faintness  caused  by 
the  erect  position;  constipation;  backache;  distress  in 
stomach  after  eating;  leucorrhea;  menstruation,  seven 
days'  duration,  painful  for  three  days.  These  symptoms 
commenced  about  eighteen  months  ago  and  have  gradu- 
ally increased  in  severit}".  Had  operation  of  appendec- 
tomy one  year  ago  for  relief  of  the  pain  in  the  side,  but 
without  beneficial  result.  Heart  normal,  82;  tempera- 
ture, 98°.     Urine  normal. 

Abdominal  examination  in  dorsal  decubitus  showed 
right  kidney  entirely  below  costal  margin  without  in- 
spiratory effort.  Kidney  painful  to  touch,  and  patient 
referred  to  it  as  the  locality  of  her  usual  pain  in  that  side. 
Some  tenderness  in  left  epigastrium. 

Vaginal  examination  showed  normal  introitus,  small 
cervix  bathed  in  mucus,  erosion  of  os,  fundus  retroverted 
to  third  degree  (easily  replaced). 

Diagnosis  of  nephrocoloptosis,  retroversion  of  uterus, 
and  endometritis.     Operation  advised. 

June  24,  1907.  Operation  at  Grace  Hospital.  Nephro- 
colopexy;  curettage;  Alexander's  operation  by  the  blunt 
hook  method.  Recovery  without  incident.  In  bed  four- 
teen days.  Wearing  abdominal  band  when  discharged, 
but  not  taking  the  oil,  as  the  bowels  were  regular. 

September  24, 1907.  Can  stand  better;  bowels  regular, 
but  has  been  taking  the  oil  occasionally,  as  there  has 


164  NEPHROCOLOPTOSIS. 

been  some  constipation  at  times.  Backache  mucli  better. 
Kidney  well  in  place,  but  lower  pole  can  be  palpated 
when  in  left  lateral  position. 

October  5,  1907.  Kidney  in  normal  position.  Patient 
died  of  pneumonia  during  the  following  winter. 

Case  24. 

Complete  cure  of  nephritic  and  colonic  symptoms,  and 
restoration  of  the  kidney  by  operation. 

Female;  aged  30;  married;  never  pregnant.  Patient 
of  Dr.  David  Inglis. 

June  10,  1907.  Seeks  relief  for  constipation;  backache; 
loss  of  strength  and  weight;  nervous  irritability;  profuse 
leucorrhea.  Has  had  the  leucorrhea  for  two  years,  and 
the  other  symptoms  for  about  a  year,  gradually  increas- 
ing. 

Abdominal  examination  in  the  dorsal  position  was 
negative,  excepting  for  a  sensitive  area  at  McBurney's 
point,  but  in  the  left  lateral  position  the  right  kidney 
dropped  down  into  the  abdomen  and  could  be  palpated  at 
the  navel. 

Vaginal  examination  showed  nothing  farther  than 
erosion  around  the  os  uteri. 

Diagnosis  of  nephrocoloptosis  and  endometritis.  Oper- 
ation advised. 

July  5,  1907.  Operation  at  Plarper  Hospital.  Nephro- 
colopexy,  curettage.  Ideal  recovery.  In  bed  eighteen 
days.  Abdominal  band  applied  and  petrolatum  oil  pre- 
scribed on  discharge  from  hospital. 

September  24,  1908.  Bowels  regular,  gained  five 
pounds,  nervous  symptoms  greatly  relieved.'  Says  everj'-- 
thing  Init  the  leucorrhea  is  very  much  improved. 

February  20,  1909.     Has  gained  eighteen  pounds  and 


EEPORTS  OF  CASES.  165 

is  very  well,  with  normal  endurance  and  very  little  of 
the  old  nervousness.  Still  troubled  with  the  leucorrhea. 
Kidney  not  palpable  in  any  position. 

Case  25. 

Disordered  nutritive  functions  and  nervous  system 
completely  restored  by  operation. 

Female;  aged  30;  single;  bookkeeper. 

September  18,  1907.  Seeks  relief  for  pain  in  back  of 
head  and  neck,  which  she  has  had  for  two  years;  loss  of 
flesh  and  strength;  pain  in  left  side  of  abdomen.  Bowels 
regular.     Torso  narrow. 

Abdominal  examination  in  dorsal  position  showed 
right  kidney  entirely  below  costal  margin  without  in- 
spiratory eitort,  and  tenderness  over  McBurney's  point. 

Pelvic  examination  showed  introitus  normal,  cervix 
small,  OS  eroded,  fundus  uteri  in  third  degree  retro- 
version (easily  replaced).  Heart  normal,  82;  tempera- 
ture normal.  Urine  normal.  Weight,  one  hundred  and 
twenty-eight  pounds. 

Diagnosis  of  nephrocoloptosis,  retroversion  of  uterus, 
and  endometritis.     Operation  advised. 

September  20,  1907.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  curettage;  Alexander's  operation  by 
the  blunt  hook  method.  Recovery  ideal.  Abdominal 
supporter  applied. 

November  4,  1907.  Kidney  and  uterus  in  normal  po- 
sition. Bowels  a  little  constipated.  Still  some  pain  in 
back  of  neck.     Petrolatum  oil  prescribed. 

April  22,  1909.  Has  gained  fifteen  pounds  since  opera- 
tion, and  now  weighs  one  hundred  and  forty-three 
pounds.  Says  she  feels  well,  and  never  knew  what  it 
was  to  feel  so  before.     Examination  showed  kiclnev  in 


166  NEPHEOCOLOPTOSIS. 

normal  position,  with  lower  pole  barely  palpable  in  left 
lateral  position.  Has  pain  only  in  back  of  head  and 
neck  when  over-fatigued.     Bowels  regular. 


Case  26. 

Rapid  gain  of  weight  after  operation. 

Female;  aged  41;  married;  mother  of  four  children, 
the  youngest  9  years  of  age. 

September  25,  1907.  Seeks  relief  for  neurasthenia; 
malnutrition  and  loss  of  jflesh;  insomnia;  constipation; 
catarrh  of  the  colon,  as  shown  by  much  mucus  in  stools; 
pain  of  both  griping  and  constant  character  in  the  right 
side  of  the  abdomen,  and  frequent  attacks  of  pain  and 
tenderness  located  on  the  right  side,  close  under  the 
costal  margin.  Had  an  attack  of  acute  intestinal  tox- 
emia five  years  before,  since  which  time  these  symptoms, 
which  had  always  been  in  evidence  for  several  years,  be- 
came very  much  worse. 

Abdominal  examination  in  the  dorsal  position  showed 
marked  sensitiveness  on  both  sides  of  the  abdomen  on 
.deep  pressure;  right  kidney  entirely  below  the  costal 
margin  on  deep  inspirator}^  effort;  left  side  negative. 

Vaginal  examination  negative.  Urine  normal.  Weight, 
one  hundred  and  ten  pounds. 

Diagnosis  of  nephrocoloptosis  and  operation  advised. 

September  20,  1907.  Operation  at  Harper  Hospital. 
Nephrocolopexy.  Convalescence  was  not  smooth,  as  a 
mild  infection  of  the  wound  was  introduced  by  the  with- 
drawal of  the  continuous  silkwormgut  stitch.  Fearing  an 
insecure  union,  the  patient  was  kept  in  bed  for  four 
weeks,  when,  the  wound  being  completely  healed,  she  was 
allowed  to  get  up.  During  the  time  in  bed  the  abdominal 
band  was  especially  cared  for  and  the  large  pad  kept 


EEPORTS  OF  CASES.  167 

bound  tightly  down  under  the  navel,  so  as  to  give  the 
kidney  every  possible  support  through  the  upward  pres- 
sure of  the  abdominal  contents.  On  assuming  the  erect 
position,  the  usual  abdominal  supporter  was  applied  and 
the  routine  of  petrolatum  oil  and  evening  enema  pre- 
scribed. The  convalescence  to  normal  after  discharge 
from  the  hospital  was  slow,  as  the  neurasthenia  persisted 
to  a  marked  degree  for  some  weeks. 

November  30,  1907.  Nutrition  improving,  as  shown 
by  five  pounds  increase  in  weight.  Bowels  regular  by 
the  daily  use  of  the  oil  and  an  occasional  enema.  Neu- 
rasthenia improving  slowly.  Still  has  some  abdominal 
pain,  but  less  of  it,  and  none  at  all  in  the  region  of  the 
kidney,  which  is  in  perfect  position. 

September  20,  1908.  Has  gained  twenty  pounds,  has 
good  color,  and  looks  in  perfect  health.  Bowels  regular 
by  the  use  of  one  daily  dose  of  the  oil.  Pain  occasion- 
ally, evidently  caused  by  distention  of  the  cecum.  Sleeps 
much  better.     Kidney  in  normal  position. 

April  30,  1909.  Has  gained  thirty-five  pounds,  and 
now  weighs  one  hundred  and  forty-five  pounds.  Is  prac- 
tically well,  excepting  for  endurance,  which  comes  slow- 
ly. The  kidney  retains  its  normal  position  when  ex- 
amined in  either  position. 

Case  27. 

A  perfect  result,  notwithstanding  infection  of  wound. 
No  doubt  the  silver  wire  stay  suture  in  the  transversalis 
fascia  prevented  failure. 

Female;  aged  57;  ]narried;  mother  of  five  children,  the 
youngest  14  years  old.     Patient  of  Dr.  C.  G.  Jennings. 

July  10,  1907.  Seeks  relief  for  irregular  and  profuse 
menstruation;  debility;  extreme  neurasthenia,  approach- 


168  NEPHROCOLOPTOSIS. 

ing  melancliolia ;  backache;  insomnia;  gradual  loss  of 
weight  during  last  two  years.  Says  bowels  are  regular. 
Had  typhoid  fever  four  years  before.  Heart  and  tem- 
perature normal;  urine  normal. 

Abdominal  examination  in  the  dorsal  position  showed 
the  right  kidney  entirely  below  the  costal  margin;  other- 
wise negative. 

Vaginal  examination  showed  everything  normal,  ex- 
cepting a  large  hyperplastic  uterus  in  the  third  degree  of 
retroversion,  which  was  readily  replaced  with  the  patient 
in  the  knee-chest  position. 

An  Albert  Smith  pessary  was  placed,  an  abdominal 
supporter  ordered,  and  tonic  prescribed. 

October  5,  1907.  As  various  forms  of  treatment  up  to 
this  time  had  proved  unsatisfactory,  operation  was 
advised. 

October  12,  1909.  Operation  at  Woman's  Hospital. 
Nephrocolopexy;  curettage;  Alexander's  operation  by 
the  blunt  hook  method. 

As  stitch  abscesses  occurred  in  all  the  wounds,  the  pa- 
tient was  kept  quiet  in  bed  for  four  weeks,  using  great 
care  to  keep  the  abdominal  pad  well  bound  in  place  to 
keep  the  kidney  supported. 

December  27,  1907.  Kidney  and  uterus  in  perfect  po- 
sition. 

January  31,  1908.  Kidney  and  uterus  in  perfect  po- 
sition. Has  gained  twenty-five  pounds;  nervous  system 
is  very  much  improved,  and  bowels  regular. 

Case  28. 

Female;  aged  47;  married;  mother  of  one  child  20  years 

old.     Patient  of  Dr.  Sarah  Conner,  of  Port  Huron,  Mich. 

December  30,  1907.     Seeks  relief  for  nervous  exhaus- 


EEPORTS  OF  CASES.  169 

tion  of  a  severe  type;  attacks  of  nausea  and  vertigo;  con- 
stipation; constant  pain  in  the  right  side  of  the  abdomen, 
which  is  more  acute  at  times  just  below  the  ribs;  pain 
lately  in  the  back  of  head;  palpitation  of  the  heart;  con- 
fusion of  ideas.  Had  total  hysterectomy  by  another  sur- 
geon twelve  years  ago  for  these  same  abdominal  pains 
and  menorrhagia.  Heart  normal,  106;  temperature  nor- 
mal. .  Urine  normal. 

Abdominal  examination  in  dorsal  position  showed  no 
abdominal  tenderness.  On  deep  inspiratory  effort  the 
right  kidney  dropped  deep  into  the  abdomen.  Operation 
advised. 

December  31,  1907.  Operation  at  Harper  Hospital. 
Nephrocolopexy.  Eecovery  without  incident.  In  bed 
sixteen  days.  Abdominal  supporter  applied  and  petro- 
latum oil  prescribed  on  discharge  from  the  hospital. 
Have  not  seen  this  patient  since  she  left  the  hospital. 
Her  husband  reported,  May  6,  1908,  that  some  of  the 
most  distressing  symptoms  had  left  her,  but  some  others 
of  a  new  character  had  appeared. 

Case  29. 

Ideal  result  in  a  case  of  long  standing*. 

Female;  aged  31;  married;  mother  of  three  chil- 
dren, the  youngest  7  months  old,  which  was  taken  from 
the  breast  three  weeks  ago.  Patient  of  Dr.  B.  H.  Jenne, 
of  Clio,  Mich. 

April  15,  1908.  Seeks  relief  for  pain  in  the  right  side 
just  below  the  ribs,  which  she  has  had  for  fifteen  years; 
cramps  in  the  l)owels  for  five  years;  frequent  nausea  and 
vomiting  of  bile;  very  intractable  constipation  for  three 
years;  gradual  loss  of  flesh.  Looks  weak  and  debilitated. 
Had  whooping-cough  seven  months  ago  and  then  had  a 


170  NEPHROCOLOPTOSIS. 

great  deal  of  pain  in  the  right  side.  Heart  normal,  112; 
temperature  normal.  Urine,  specific  gravity,  1,026;  acid; 
no  albumin;  heavy  with  urates. 

Abdominal  examination  in.  the  dorsal  position  showed 
some  sensitiveness  at  McBurney's  point,  but  more  under 
the  costal  margin  on  the  right  side,  when  inspiratory 
effort  brought  down  the  right  kidney  entirely  below  the 
ribs,  and  with  (and  apparently  attached  to  the  front  of 
it)  an  irregular  rough-feeling  mass  that  nearly  covered 
it,  and  yet  could  be  moved  somewhat  separately. 

Vaginal  examination  showed  a  ruptured  perineum  of 
second  degree;  cervix  normal;  normal  sized  uterus  in 
third  degree  of  retroversion  (easily  replaced  in  knee 
chest  position). 

Sent  to  Harper  Hospital  and  a  blood  examination 
made,  which  was  negative,  after  which  operation  was 
advised,  as  farther  examination  of  the  mass  on  the  dis- 
placed kidney  led  to  the  belief  that  it  was  probably  the 
remains  of  an  exudate  caused  by  an  attack  of  Dietl's 
crisis,  which  may  have  occurred  at  the  time  the  patient 
had  the  whooping-cough. 

April  17,  1908.  Operation.  Nephrocolopexy;  perine- 
orrhaphy (split  flap,  buried  suture  of  No.  1  twenty-day 
cutgut);  Alexander's  operation  by  the  blunt  hook 
(buried  suture)  method.  At  the  operation  the  kidney 
was  thoroughly  examined  when  reached  through  the  loin 
incision,  and  the  organ  was  found  to  be  perfectly  normal 
in  contour,  the  mass  being  entirely  separate  from  it. 

Eecovery  was  ideal  in  every  way,  and  patient  left  the 
hospital  at  the  end  of  five  weeks.  Abdominal  support 
applied  and  petrolatum  oil  prescribed. 

September  29,  1908.  Patient  says:  "Haven't  an  ache 
or  a  pain,  sleep  well,  have  gained  ten  pounds.  Took  the 
oil  for  two  months,  but  have  not  needed  it  since,  as  the 
bowels  are  perfectly  regular." 


REPORTS  OF  CASES.  171 

Examination  showed  the  kidney  in  normal  position; 
could  be  forced  down  so  that  only  the  lower  pole  could 
be  palpated. 

November  22,  1909.  Dr.  Jenne  reports  that  she  is  fat, 
has  gained  fifteen  poimds,  and  is  very  well  in  every  way. 

Case  30. 

Ideal  result  in  a  case  complicated  by  intra-abdominal 
surgery. 

Female;  aged  23;  single;  stenographer.  Patient  of  Dr. 
J.  H.  Sanderson. 

March  5,  1908.  Seeks  relief  for  nearly  constant  back- 
ache; "bearing  down"  in  the  abdomen;  a  "smarting" 
sensation  in  the  lower  left  side  of  the  abdomen,  near  the 
groin;  increasingly  severe  dysmenorrhea  for  a  year.  Had 
curettage  twice — four  years  ago  and  one  year  ago — with 
only  temporary  relief  of  the  dysmenorrhea  and  no  relief 
of  the  other  symptoms.  Has  lost  flesh  steadily  for  two 
years — eleven  pounds  during  the  last  six  months.  Nor- 
mal weight,  one  hundred  and  thirty-five  pounds;  now 
weighs  one  hundred  and  sixteen  pounds.  Bowels  regu- 
lar. Heart  normal,  84;  temperature  normal.  Urine 
normal.     Complexion  muddy  and  skin  rough. 

Abdominal  examination  showed  right  kidney  entirely 
below  the  costal  margin  on  deep  inspiration;  left  kidney 
in  normal  position;  no  abdominal  tenderness,  except  just 
above  Poupart's  ligament  on  the  left  side  on  deep 
pressure. 

Examination  of  pelvic  organs  obscured  by  fecal  mass 
in  the  sigmoid  and  rectum.  Directions  were  given  to 
clear  the  colon  by  laxative  and  enema,  and  to  return  for 
further  examination. 

March  9,  1908.     Pelvic  examination  showed  everything 


172  NEPHEOCOLOPTOSIS. 

normal,  excepting  the  left  ovary,  which  was  twice  normal 
size;  very  sensitive,  bnt  not  adherent. 

Diagnosis  of  nephrocoloptosis  and  left  cystic  ovary, 
and  operation  advised. 

April  28,  1908.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  abdominal  section,  with  left  oophorectomy. 
Ovary  large  and  cystic.  Recovery  ideal  in  every  way. 
In  bed  eighteen  days.  Applied  abdominal  supporter  on 
discharge  from  hospital. 

July  8,  1909.     Feels  much  better  in  every  way. 

October  16,  1909.  Gained  twenty-five  jDounds;  dys- 
menorrhea better;  bowels  somewhat  constipated,  and  has 
been  using  the  petrolatum  oil  and  an  occasional  enema. 

March  29,  1909.  Has  kept  the  weight  as  reported  in 
October.  Bowels  normal;  no  headache  or  "bearing 
down;"  endurance  very  good;  marked  improvement  in 
complexion  and  smoothness  of  skin.  Kidney  in  normal 
position  and  can  not  be  brought  down  by  posture. 

September  19,  1909.  Feels  perfectly  well,  and  asks 
permission  to  discard  the  abdominal  supporter,  which 
was  granted. 

Case  31. 

A  good  anatomic  result,  with  failure  of  symptomatic 
cure  because  of  conditions  of  apparent  neurotic  origin. 

Female;  aged  45;  married;  mother  of  two  children,  the 
youngest  22  years  old.  Patient  of  Dr.  S.  P.  Duffield,  of 
Dearborn. 

March  30,  1908.  Seeks  relief  for  a  feeling  of  pressure 
in  the  abdomen  and  of  distention  at  the  vulva;  frequent 
abdominal  pain,  more  frequently  in  the  left  side;  gen- 
eral weakness  and  neurasthenia,  with  hysterical  tend- 
ency; insomnia.  Patient  constantly  talks  of  something 
having  ''broken"  at  the  vulva,  following  a  trachelor- 


EEPORTS  OF  CASES.  173 

rliaiDliy  by  another  surgeon  two  and  a  half  years  ago, 
and  appears  to  be  liypocliondriacal  on  the  subject.  Men- 
struation regular,  but  profuse  at  times.  Heart  normal, 
90;  temperature  normal.     Urine  normal. 

Abdominal  examination  in  the  left  lateral  decubitus 
showed  the  right  kidney  entirely  below  the  costal  margin, 
and  abdominal  tenderness  in  left  epigastrium. 

Vaginal  examination  showed  ruptured  perineum  of 
second  degree  and  large  hyperplastic  uterus.  Operation 
recommended,  though  the  peculiar  neurotic  element  in 
the  case  made  the  prognosis  guarded. 

May  28,  1908.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  perineorrhaphy;  curettage.  Recovery  with- 
out incident,  though  strength  returned  slowly  after  get- 
ting up  and  mental  condition  was  sluggish.  Abdominal 
supporter  applied  on  discharge  from  hospital. 

October  6,  1908.  Pain  and  pressure  in  vulva  gone,  Init 
thinks  now  she  has  ''broken  something"  in  the  kidney. 
Examination  showed  kidney  in  normal  position  and  not 
sensitive.     Gained  in  flesh,  but  says  she  sleeps  badly. 

February  17,  1909.  Kidney  in  normal  position;  bowels 
regular,  and  patient  in  good  appearing  condition,  but 
complains  again  of  "something  broken"  in  the  vulva. 
Was  sent  to  the  hospital  and  various  examinations  made, 
with  only  negative  results. 

Case  32. 

Operation  on  kidney  having-  pathologic  surroundings 
gives  no  relief  of  symptoms. 

Female;  aged  38;  married;  mother  of  one  child  11 
years  old. 

July  2,  1908.  Seeks  relief  for  frequent  attacks  of  grip- 
ing  pain   in   abdomen,   and  nearly   constant   pain   and 


174  NEPHROCOLOPTOSIS. 

tenderness  below  the  ribs  on  the  right  side;  gradual  loss 
of  flesh  for  three  years  (weighs  one  hundred  and  eight 
pounds);  extreme  nervous  irritability;  insomnia;  fre- 
quent headaches;  has  menstruated  but  twice  in  the  last 
eight  months  (the  last  time  slightly,  in  May).  Torso 
very  narrow  and  the  lower  thoracic  zone  contracted. 
Heart  normal,  90;  temperature  normal.    Urine  normal. 

Abdominal  examination  in  dorsal  position  showed 
right  kidney  entirely  below  the  costal  margin  without 
inspiratory  effort.  Impossible  to  replace  the  organ  en- 
tirely back  into  its  normal  position  behind  the  costal 
margin,  the  renal  fossa  being  apparently  filled  or  closed, 
so  that  the  kidney  could  be  replaced  only  partially,  and 
would  then  drop  back  at  once  by  its  own  weight.  The 
whole  abdomen  was  sensitive  to  touch. 

Vaginal  examination  showed  pelvic  organs  normal,  ex- 
cepting the  uterus,  which  was  very  small,  and  apparently 
undergoing  atrophy.  Eadiograph  of  the  colon  to  be 
made. 

July  4,  1908.  Radiograph  showed  the  cecum  in  the 
bottom  of  the  pelvis,  and  very  large.  The  transverse 
colon  did  not  show  at  all.  Operation  advised,  although 
the  difficulty  of  replacing  the  kidney  normally  should 
have  demanded  treatment  for  a  time  and  longer  observa- 
tion. The  peculiar  situation  of  the  patient  at  the  time 
precluded  this  delay,  and  I  therefore  concluded  to  take 
the  chance  of  immediate  operation. 

July  7,  1908.  Operation  at  Harper  Hospital.  Nephro- 
colopexy.  The  nephro colic  ligament  was  large,  but  it 
was  impossible  to  draw  or  push  the  kidney  up  into  the 
fossa  far  enough  to  secure  it  below  the  pole,  and  the 
mistake  was  made  of  attaching  that  portion  of  it  which 
lay  parallel  with  the  convexity  of  the  kidney,  hoping 
that  its  good  volume  would  serve  to  hold  sufficiently. 


EEPORTS  OF  CASES.  175 

Recovery  was  without  incident,  and  patient  left  the 
hospital  at  the  end  of  four  weeks.  Al)dominal  supporter 
applied  and  petrolatum  oil  prescribed. 

November  7,  1908.  The  whole  kidney  can  be  felt  lying- 
close  to  the  side  where  attached,  and  does  not  drop  into 
the  abdomen,  toward  the  navel,  as  before  oioeration. 
Patient's  symptoms,  however,  she  reports,  are  not  re- 
lieved. 

December  31,  1909.  Weighs  one  hundred  and  twelve 
pounds;  bowels  regular;  still  has  some  pain  in  both  sides 
of  abdomen,  though  gradually  decreasing;  sleeps  very 
much  better;  kidney  still  fixed,  though  entirely  below 
costal  margin. 

Case  33. 

Good  result,  anatomically  and  symptomatically,  three 
months  after  operation. 

Female;  aged  30;  married;  mother  of  three  children, 
youngest  2  years  old.     Clinical  patient. 

September  26,  1909.  Seeks  relief  for  backache;  ab- 
dominal pain,  located  in  both  sides;  frequent  attacks  of 
nausea  without  emesis;  gradual  loss  of  weight  and 
strength,  and  resultant  inability  to  work;  constipation; 
nervousness;  insomnia.  Heart,  temperature,  and  urine 
normal. 

Abdominal  examination  showed  right  kidney  entirely 
below  the  costal  margin;  sensitiveness  in  left  epigas- 
trium. 

Vaginal  examination  showed  everything  normal,  ex- 
cepting a  uterus  of  normal  size  in  third  degree  retro- 
version, which  was  easily  replaced,  manually,  with  the 
patient  in  the  knee-chest  position. 

Diagnosis  of  nephrocoloptosis  and  retroversion,  and 
operation  advised. 


176  NEPHROCOLOPTOSIS. 

Sei^tember  30,  1908.  Operation  at  Harper  HosxDital. 
Neplirocolopexy;  Alexander's  operation  by  the  blnnt 
hook  method.  Recovery  uneventful.  Abdominal  sup- 
porter applied  and  petrolatum  oil  prescribed  on  dis- 
charge from  hosi3ital. 

December  25,  1908.  Kidney  in  normal  position  and 
not  palpable  in  any  position.  Bowels  regular  by  the  use 
of  the  oil  once  a  day.  Gaining  in  flesh  and  strength. 
Patient  not  seen  since. 

Case  34. 

Extreme  neurasthenia. 

Female;  aged  42;  married;  mother  of  two  children,  the 
youngest  6  years  old.  Patient  of  Dr.  Thomas,  of  North 
Branch,  Mich. 

November  1,  1908.  Seeks  relief  for  neurasthenia;  con- 
stant headache;  progressive  emaciation;  almost  constant 
pain  in  abdomen,  back,  and  thighs;  alternating  constipa- 
tion and  diarrhea;  frequent  micturition;  insomnia — can 
never  sleep  on  the  left  side  because  of  palpitation;  says 
she  has  always  had  the  abdominal  pains.  Is  a  chronic 
invalid,  and  unable  to  stand  or  walk  but  for  a  few  min- 
utes at  a  time.  Had  operation  for  cervical  stenosis  at 
19.  AVas  badly  lacerated  at  childbirth,  and  says  she  has 
been  "sewed  up"  three  times  for  it.  Heart  normal,  100; 
temperature  normal.     Urine  normal. 

Abdominal  examination  in  the  dorsal  position  showed 
great  sensitiveness  all  over,  the  especial  points  being  at 
the  right  of  the  navel  and  just  below  it  on  deep  pressure; 
the  right  kidne}^  entirely  below  the  costal  margin,  with- 
out effort- — not  very  movable  in  further  descensus,  and 
easily  replaced. 

Vaginal  examination  showed  a  normal  appearing  peri- 
neum, which  on  close  inspection  proved  to  be  composed 


EEPORTS  OF  CASES. 


177 


of  skin  only,  the  onl}^  muscular  portion  intact  being  a 
very  small  part  of  the  sphincter  ani;  cervix  uteri  large, 
cystic,  eroded,  and  lacerated  left  laterally;  uterus  hyper- 
plastic, normal  position;  appendages  normal. 

November  2,  1908.  Radiograph  showed  ptosis  of  the 
colon,  as  illustrated  in  Fig.  51.  Diagnosis  of  right  neph- 
rocolo]3tosis,  ruptured  perineum  of  second  degree,  left 
laceration  of  cervix  uteri,  and  endometritis.  Operation 
advised. 


Fig.  51.     Case  34. 


November  3,  1908.  Operation  at  St.  Mary's  Hospital. 
Nephrocolopexy;  i^erineorrhaphy  (split  flap  method  and 
buried  No.  1  twenty-day  catgut) ;  trachelorrhaphy;  cu- 
rettage. The  wound  in  the  loin  healed  perfectly;  the 
perineal  wound  suppurated  slightly,  but  careful  atten- 
tion ended  in  a  perfect  result.  In  bed  five  weeks,  the 
last  two  because  of  debility,  and  also  a  desire  to  benefit 
the  nervous  system  by  rest  and  forced  feeding.  On  dis- 
charge from  the  hospital  the  alidominal  supporter  was 
applied  and  i^etrolatum  oil  prescribed. 

July  3,  1909.     Has  gained  thirteen  pounds,  and  feels 


178  NEPHEOCOLOPTOSIS. 

better  and  stronger  in  every  way.  Still  lias  some  ab- 
dominal tenderness,  and  her  nerve  tone  and  endurance 
are  returning  slowly.  Bowels  regular  by  the  use  of  the 
petrolatum  oil  once  daily;  kidney  in  normal  position. 

Case  35. 

A  case  in  point  where  a  uric  acid  diathesis  protracts 
recovery  and  proves  an  important  factor  in  post-opera- 
tive treatment.  Such  cases  should  be  recognized  and  re- 
ceive adequate  treatment  before  operation.  Case  also 
remarkable  for  good  anatomic  result,  notwithstanding 
post-operative  infection  of  wound — showing  value  of  the 
silver  wire  suture. 

Female;  aged  44;  married;  mother  of  one  child,  9  years 
old. 

October  27,  1908.  Seeks  relief  for  pain  and  burning- 
sensation  in  the  stomach  and  bowels;  palpitation  of  the 
heart;  sick  headaches;  meuorrhagia  and  menses  of  foul 
odor;  loss  of  flesh  and  streng-th.  All  symptoms  came  on 
gradually  during  the  last  year.  Complexion  dark  and 
muddy  and  skin  rough.  Heart  normal,  90;  temperature 
normal.  Urine,  specific  gravity,  1,028;  acid;  loaded  with 
sediment  composed  of  uric  acid,  urates,  and  epithelium. 
No  albumin  or  sugar. 

Abdominal  examination  in  the  dorsal  position  showed 
the  right  kidney  entirely  below  the  costal  margin  without 
effort,  and  well  down  in  the  abdomen,  near  the  navel,  on 
deep  inspiration;  easily  replaced  manually.  Left  kidney 
not  palpable  in  any  position. 

Vaginal  examination  showed  a  ruptured  perineum  of 
second  degree;  normal  uterus  and  cervix;  the  latter  hav- 
ing a  mucous  polyp  of  about  an  inch  in  length  hanging 
from  it  and  passing  into  its  attachment  near  the  inner  os. 
Operation  advised. 


EEPORTS  OF  CASES.  179 

November  11,  1908.  Operation  at  Harper  Hospital. 
Neplirocolopexy;  perineorrhaphy;  excision  of  polyp;  and 
curettage.  A  stormy  convalescence  followed,  due  large- 
ly to  the  uric  acid  diathesis  of  the  patient,  and  partly  to 
a  mild  infection  of  the  wound  in  the  loin  following  the 
removal  of  the  continuous  subcutaneous  silkwormgut 
suture  (the  last  used  by  me  in  these  cases). 

There  was  slight  febrile  action  lasting  for  three  days 
following  the  infection  of  the  wound,  but  after  that  the 
temperature  remained  practically  normal,  or  subnormal, 
throughout. 

A  j)rominent  symptom  which  continued  for  three 
weeks  was  pain  of  a  severe  character,  occurring  fre- 
quently in  various  parts  of  the  body,  legs,  and  arms.  The 
treatment  was  principally  eliminative  in  character  and 
the  use  of  acid,  nitromur.  dilut.  and  aspirin.  In  bed  four 
weeks.  Discharged  December  12,  1908,  in  good  con- 
dition and  both  wounds  healed. 

February  6,  1909.  Wound  in  loin  open  and  discharg- 
ing slightly;  on  probing  found  silver  wire  suture  had  be- 
come untwisted  (silver  shot  not  used  in  this  case)  and 
was  causing  a  mechanical  irritation,  and  was  removed. 
Kidney  in  normal  position. 

March  7,  1909.  Kidney  in  normal  position  and  not 
palpable.     Bowels  regular  without  medication. 

October  25,  1909.  Kidney  in  normal  position  and 
bowels  regular.  Has  gained  six  pounds  since  operation. 
Troubled  a  good  deal  with  rheumatic  pains.  Urine 
turbid  with  urates.     Prescribed  acid,  nitromur.  dilut. 

January  10,  1910.  Has  gained  ten  pounds  since  opera- 
tion; kidney  in  normal  position. 


180  NEPHEOCOLOPTOSIS. 

Case  36. 

Ideal  anatomic  and  symptomatic  result  of  fixation. 

Female;  aged  31;  married;  mother  of  seven  children, 
the  youngest  1  year  old. 

November  25,  1908.  Seeks  relief  for  constant  head- 
ache; pain  of  both  dull  and  griping  character  in  the  left 
side  of  abdomen;  constii^ation,  the  movements  being  pre- 
ceded by  cramps;  loss  of  flesh  and  strength;  menor- 
rhagia;  leucorrhea.  Had  lacerated  cervix  repaired  six 
months  ago  by  another  surgeon.  Heart  normal,  100; 
temperature  normal.     Urine  normal. 

Abdominal  examination  showed  a  broad,  flat  abdomen, 
with  widely  expanded  lower  thoracic  zone;  sensitive  in 
left  epigastrium;  right  kidney  completel}^  down  in  the 
abdomen  with  patient  in  the  left  lateral  decubitus. 

Vaginal  examination  showed  good  perineum;  repaired 
cervix;  large  uterus,  with  soft  fundus  in  third  degree  of 
retroversion,  easily  replaced  in  the  knee-chest  position. 

November  6,  1908.  Radiograph  made,  but  proved  a 
failure,  owing  to  the  rapid  descent  of  the  bismuth  into 
the  descending  colon,  sigmoid,  and  rectum  because  of  the 
previous  use  of  a  cathartic. 

November  28,  1908.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  curettage;  Alexander's  operation.  Re- 
covery without  incident.  In  bed  eighteen  da^^s.  Ab- 
dominal supporter  applied  and  petrolatum  oil  prescribed 
on  discharge  from  hospital. 

January  13,  1909.  Bowels  regular  by  use  of  the  petro- 
latum oil ;  kidney  and  uterus  in  normal  position. 

February  22,  1909.  Bowels  regular  by  taking  the  oil 
once  a  day;  no  more  abdominal  pains;  no  leucorrhea; 
menstruates  normally;  kidney  and  uterus  both  in  normal 
position. 


EEPORTS  OF  CASES.  181 

April  15,  1909.  Bowels  regular,  without  oil,  and  no 
''cramps;"  kidney  in  normal  position,  with  lower  pole 
just  palpable  with  patient  in  left  lateral  decubitus  and 
deei^  inspiratory  effort;  gained  ten  pounds. 

Case  37. 

Remarkable  immediate  improvement  following  opera- 
tion in  a  typical  case  showing  extreme  neurasthenia. 

Female;  aged  42;  married  eighteen  years;  mother  of 
one  child  16  years  old;  menstrual  history  normal.  Ee- 
ferred  to  me  by  Dr.  T.  A.  McGraw. 

February  27,  1909.  Seeks  relief  for  neurasthenia;  gen- 
eral debility;  malnutrition;  dyspepsia;  loss  of  memory, 
etc.  Thinks  iniury  in  a  railroad  accident  many  years 
ago  caused  a  shock  to  the  nervous  system,  and  that  the 
present  illness  is  due  to  it.  Has  lost  thirty  pounds  in 
five  years.  Spends  most  of  her  time  lying  down.  Con- 
stipation very  troublesome,  requiring  daily  medication 
or  enema.  Mentality  much  impaired,  being  unable  to 
carry  on  a  connected  conversation.  Has  no  hallucina- 
tions. Sleeps  little  and  never  on  the  left  side.  Frequent 
griping  pain  in  bowels  and  mucus  in  stools.  Most  pain 
in  left  side  of  abdomen.  Has  been  in  sanitariums  and 
health  resorts  for  years,  with  no  benefit,  and  has  con- 
sulted various  kinds  of  specialists,  from  the  neurologist 
to  the  osteopath,  without  benefit.  They  all  advised 
change  of  scene  and  climate  after  unsuccessful  periods  of 
treatment.  The  diagnosis  was  usually  ''neurasthenia" 
and  "intestinal  indigestion." 

February  27,  1909.  Examination  made.  Facial  ex- 
pression drawn  and  tired-looking;  complexion  muddy,  al- 
most to  jaundice.  Abdominal  walls  thick,  flaccid,  and 
relaxed.     Deep  inspiration,  dorsal  position,  right  kidney 


182 


NEPHROCOLOPTOSIS. 


can  be  felt  down  to  the  umbilicus,  and  does  not  return 
without  manual  assistance.  With  patient  on  the  left  side 
and  knees  drawn  up,  the  kidney  is  felt  well  in  the  median 
line.  Left  kidney  not  displaced.  Some  tenderness  at 
McBurney's  point — cecum  and  ascending  colon — ^not  the 
appendix.     (See  Fig.  52  for  position  of  appendix.) 

Vaginal  examination  showed  ruptured  perineum  of 
second  degree,  rectocele,  and  uterine  hyperplasia. 

February  28,  1909.  X-ray  (Fig.  52)  showed  the  cecum 
in  the  bottom  of  the  pelvis  as  far  as  gravity  could  take 


Fig.   52.     Case  37. 

it,  and  the  transverse  colon  very  low,  causing  sharp  angu- 
lation at  the  splenic  flexure  (cause  of  pain  in  this  side). 
Operation  recommended. 

March  4,  1909.  Operation  at  Harper  Hospital.  Nepli- 
rocolopexy;  perineorrhaphy;  curettage.  In  bed  three 
weeks.     Recovery  ideal  in  every  way. 

April  1,  1909.     Discharged  from  hospital. 

April  17,  1909.  Bowels  regular,  without  medication  of 
any  kind  since  operation;  feels  well  and  is  gaining  in 
flesh.     Left  for  Atlantic  City. 


EEPORTS  OF  CASES.  183 

May  20,  1909.  Returned  from  Atlantic  City.  Bowels 
regular  and  appetite  good;  has  no  abdominal  pain,  and 
has  gained  eighteen  pounds. 

July  30,  1909.  Bowels  regular;  often  walks  two  miles 
a  day  without  fatigue;  sleeps  well;  has  gained  thirty-two 
pounds  since  operation;  mentality  greatly  improved,  is 
sprightly  and  vivacious,  and  enjoys  life.  On  sending  her 
to  Dr.  Hickey  for  another  x-ray,  he  was  especially  struck 
with  the  greatly  improved  facial  expression  and  mental 
tone.  Radiograph  a  poor  one.  (Dr.  Hickey  said  I  had 
made  her  too  fat  for  a  good  one.) 

Case  38. 

A  common  cause  of  ''nervous  breakdown"  in  a  young 
subject,  caused  by  a  right  nephrocoloptosis,  cured  by 
operation. 

Female;  aged  25;  single. 

January  18,  1900.  Seeks  relief  for  neurasthenia;  mal- 
nutrition; debility;  headaches;  dizziness;  nausea;  flatu- 
lence; "cramps"  in  the  abdomen;  sleeplessness;  dysmen- 
orrhea. Never  can  sleep  on  the  left  side,  as  it  causes 
palpitation  of  the  heart.  Bowels  constipated,  and  re- 
quire constant  attention  by  medication  and  enema. 
Heart  and  temperature  normal.     Urine  normal. 

Abdominal  examination  shows  right  kidney  entirely 
below  costal  margin.  Left  lateral  position,  with  deep 
inspiration,  necessary  to  bring  it  down,  when  it  remained 
so  until  replaced  manually.  Vaginal  examination  nega- 
tive. 

Radiograph  of  the  colon  showed  a  moderate  coloptosis 
of  the  transverse  section  and  a  marked  ptosis  of  the  cecal 
end  of  the  gut.     (Fig.  53.)     Operation  advised. 

April  13,  1909.     Operation  at  Harper  Hospital.     Neph- 


184 


NEPHROCOLOPTOSIS. 


rocolopexy;  dilatation  of  the  cervix  uteri.  Weight  at 
operation,  ninety-four  pounds;  weight  elune  7,  1909,  one 
hundred  pounds;  weight  September  1,  1909,  one  hundred 


Fig-.   53.     Case  38. 

and  six  pounds,  when  she  reported  bowels  in  perfect  con- 
dition; has  discontinued  the  petrolatum  oil. 

December  12,  1909.  Kidney  in  normal  position. 
Weight,  one  hundred  and  eight  pounds. 

Case  39. 

A  chronic  invalid,  having  extreme  neurasthenia  and 
malnutrition,  cured  by  operation. 

Female;  aged  37;  married;  one  child. 

March  2, 1909.  Seeks  relief  for  neurasthenia,  approach- 
ing melancholia  in  spells  of  depression;  nervous  irritabil- 
ity; dyspepsia;  diarrhea;  pain  over  whole  abdomen,  but 
especially  in  left  side;  emaciation;  muddy  complexion. 
Has  passed  the  greater  part  of  the  past  two  years  in  sani- 
tariums and  health  resorts,  and  has  consulted  various 
specialists.  Was  treated  by  all  of  them  for  neurasthenia, 
intestinal  indigestion,  and  toxemia,  and  had  all  kinds  of 


EEPORTS  OF  CASES. 


185 


examinations  of  blood  and  secretions  made.  Sleeps  well, 
which  is  unusual  in  these  cases.  Normal  weight,  one  hun- 
dred and  twenty  pounds;  present  weight,  one  hundred 
and  ten  pounds. 

Abdominal  examination  showed  the  right  kidney  en- 
tirely below  the  costal  margin  while  in  the  dorsal  po- 
sition, without  respiratory  effort,  and  sensitiveness  in  left 
hypochondrium.     Vaginal  examination  negative. 


Fig.   54.     Case  39. 


March  5,  1909.  Radiograph  shows  cecum  and  ascend- 
ing colon  nearly  completely  below  McBurney's  point,  the 
first  half  of  the  transverse  colon  very  low  in  the  pelvis, 
and  the  distal  portion  in  a  position  parallel  to  the  de- 
scending colon.     (Fig.  54.) 

May  6,  1909.  Operation  at  Harper  Hospital.  Nephro- 
colopexy.  In  l)ed  eighteen  days.  Recovery  without  in- 
cident. Abdominal  supporter  applied  and  petrolatum  oil 
prescribed  on  discharge  from  the  hospital. 

September  29,  1909.  Reports  great  improvement  in 
every  way.  Gained  ten  pounds;  complexion  is  clear; 
bowel  movements  improving;  rarely  has  diarrhea.     Her 


186 


NEPHEOCOLOPTOSIS. 


family  reports  great  improvement  in  the  nervous  irrita- 
bility. Rarely  has  pain  in  the  left  side,  and  only  occa- 
sional attacks  of  indigestion. 

December  20,  1909.  Weighs  one  hundred  and  twenty- 
five  pounds,  and  is  well  in  every  respect;  bowels  regular; 
kidney  in  normal  position. 

Case  40. 

Dietl's  crisis — typical  case — cured  by  operation. 

Female;  aged  26;  married  two  months.  Was  always 
thin  and  dyspeptic,  and  bowels  constipated.  Patient  of 
Dr.  C.  G.  Jennings. 


Fig-.   55.      Case  40. 

Gastroptosis  diagnosticated  a  year  before  and  has 
worn  an  abdominal  support  for  it.  Has  had  two  attacks 
of  Dietl's  crisis — one  three  weeks  before  marriage  and 
the  other  two  weeks  after  that  event.  Had  fever  with 
both  attacks,  which  were  also  attended  with  much  swell- 
ing of  the  right  kidney  and  surrounding  structures,  with 
albumin,  casts,  and  red  blood  cells  in  the  urine,  which 
condition  persisted  for  some  time  after  the  subsidence 
of  the  acute  symptoms. 


REPORTS  OF  CASES.  187 

Patient  sent  to  St.  Mary's  Hospital  and  pnt  to  bed 
after  the  second  attack,  and  kept  under  treatment,  with 
absohite  rest,  for  four  weeks,  when,  all  indication  and 
symptoms  of  local  irritation  having  subsided  and  the 
urine  cleared  up,  the  operation  of  nephrocolopexy  was 
performed  on  June  12,  1909.  A  retroverted  uterus  was 
restored  by  the  Alexander  operation  at  the  same  time. 
Eecovery  without  incident.  In  bed  four  weeks.  A 
radiograph  taken  the  day  before  operation  (Fig.  55) 
shows  the  result  of  great  relaxation  of  the  hepatocolic 
ligament,  the  cecum,  ascending  colon,  and  much  of  the 
transverse  colon  lying  low  in  the  pelvis. 

August  20,  1909.  Eeported  in  good  condition.  No 
pain,  bowels  regular  by  using  petrolatum  oil,  appetite 
good,  and  increasing  in  weight.  Kidney  in  normal  po- 
sition. 

November  20,  1909.  Reports  from  abroad,  where  she 
went  in  September,  that  she  is  perfectly  well  and  getting 
fat. 

Case  41. 

Ideal  rapid  recovery  and  ideal  anatomic  result  of 
operation. 

Female;  aged  33;  married,  never  pregnant.  Patient  of 
Dr.  F.  J.  Langlois,  of  Wyandotte,  Mich. 

January  21,  1909.  Seeks  relief  for  frequent  attacks 
of  pain  in  the  middle  and  right  side  of  abdomen,  and 
also  in  the  back  of  head  and  neck;  "heartburn;''  severe 
constipation — defecation  often  causes  the  occurrence  of 
the  abdominal  pain;  frequent  micturition,  which  also 
seems  to  start  the  pain;  menstruation  irregular  (three  to 
six  weeks),  very  painful,  free  and  clotted,  and  continues 
for  ten  days;  loss  of  flesh — twenty  pounds  in  two  years; 
all  symptoms  have  been  gradual  in  commencement,  and 


188  NEPHEOCOLOPTOSIS. 

have  been  present  for  about  two  years.  Heart  normal, 
84;  temperature  normal;  urine  normal.  Weight  now  one 
hundred  and  eighteen  pounds. 

Abdominal  examination  in  dorsal  decubitus  shows 
great  tenderness  in  all  of  right  side,  but  esiDecially  in 
right  epigastrium;  on  deep  inspiration  right  kidney  is 
forced  down  entirelj^  below  the  costal  margin.  Left  kid- 
ney not  palpable. 

Vaginal  examination  shows  normal  perineum;  normal 
cervix  uteri  containing  a  large  cyst;  uterus  hyperplastic, 
and  in  normal  position  and  mobility.     Operation  advised. 

June  23,  1909.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  curettage;  removal  of  small  intra-uterine 
mucous  polyp;  scarification  of  cervix. 

Eecovery  without  incident.  In  bed  eighteen  days. 
Abdominal  supporter  applied  and  petrolatum  oil  pre- 
scribed on  discharge  from  hospital. 

March  22,  1909.  Defecation  regular  by  the  use  of  the 
oil  only;  menstruation  normal;  gaining  in  weight;  kidney 
in  normal  position  in  any  position. 

April  26,  1909.  Bowels  regular  with  one  dose  of  oil 
daily;  weight,  one  hundred  and  thirty-two  pounds,  and  is 
steadily  gaining.  Feels  quite  well,  and  says  her  endur- 
ance returns  slowly,  but,  as  she  tells  of  walking  two  and 
a  half  miles  the  day  before,  whereas  before  operation 
walking  any  distance  was  impossible,  the  "endurance" 
can  be  put  down  as  "very  good."  Has  occasional  pain 
and  a  pulling  sensation  in  and  around  the  kidney  and  in 
the  scar.  Rarely  has  pain  in  the  back  of  the  neck  and 
head.     Kidney  not  j)alpable  in  any  position. 


EEPORTS  OF  CASES.  189 


Case  42. 


Patient  having  had  Dietl's  crisis,  mistaken  for  attacks 
of  appendicitis.  Cured  by  operation.  Rapid  increase  in 
weight. 

Female;  aged  26;  single;  stenographer. 

June  3,  1909.  Seeks  relief  for  pains  in  back  and  right 
side  of  abdomen;  loss  of  flesh — twenty-five  pounds  in  ten 
months;  dysjDepsia;  dysmenorrhea;  severe  constipation, 
relieved  only  by  high  colonic  flushing;  neurasthenia  and 
loss  of  strength;  inability  to  do  her  work.  Says  she  had 
two  attacks  of  "appendicitis,"  one  in  August  last,  which 
laid  her  up  for  six  weeks,  and  another  two  months  later, 
wdiich  lasted  two  weeks.  In  both  attacks  she  referred 
the  seat  of  pain  and  swelling — which  she  said  was 
marked — high  up  in  the  right  side,  close  to  the  costal 
margin.  Complexion  muddy  and  skin  rough.  Heart  and 
temperature  normal;  urine  normal,  excepting  for  pres- 
ence of  amorphous  urates.  Weight,  one  hundred  and  ten 
pounds. 

Examination  in  dorsal  decubitus  shows  no  sensitive- 
ness at  McBurney's  point,  but  a  good  deal  above,  close 
to  the  ribs.  Kidneys  not  palpable  in  this  position.  In 
the  left  lateral  decubitus  the  right  kidney  dropped  low  in 
the  abdomen  on  deep  inspiration,  and  was  easily  replaced 
manually.     Left  kidney  not  palpable. 

Vaginal  examination  showed  perineum  and  cervix  nor- 
mal; uterus  hyperplastic  and  in  the  third  degree  retro- 
version, and  easily  replaced  in  the  knee-chest  position. 

The  results  of  the  examination  convinced  me  that  the 
previous  attacks  of  "appendicitis"  were  no  doubt  at- 
tacks of  Dietl's  crisis.     Operation  advised. 

June  29,  1909.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  curettage;  Alexander's  operation.    Eecovery 


190  NEPHROCOLOPTOSIS. 

witlioiit  incident.  In  bed  eighteen  days.  Abdominal 
supporter  applied  and  petrolatum  oil  prescribed  on  dis- 
charge from  hospital. 

October  15,  1909.  Kidney  in  normal  position  and  can 
not  be  brought  down  in  either  position.  Uterus  in 
normal  position.  Is  g-aining  in  weight,  and  the  complex- 
ion is  clearing. 

December  15,  1909.  Kidney  in  normal  position,  and 
stands  the  test  of  the  left  lateral  position  without  appear- 
ing at  all  below  the  costal  margin.  Patient  says  all  sen- 
sitiveness in  the  region  of  the  kidney,  which  was  so  mani- 
fest before  operation,  is  entirely  gone.  Sometimes  has 
transient  pain  in  the  cecum,  caused  by  gas  (common 
symptom  for  several  months  after  operation).  Bowels 
are  perfectly  regular  by  the  use  of  one  daily  dose  of  the 
petrolatum  oil;  enema  not  necessary.  Sleeps  and  eats 
well.  Weighs  one  hundred  and  thirty-one  pounds,  a 
gain  of  twenty-one  pounds  since  operation.  Complexion 
perfectly  clear.    . 

Case  43. 

Coloptosis  without  nephroptosis,  cured  of  intestinal 
symptoms  by  the  operation  of  nephrocolopexy.  (Radio- 
graphed before  and  after  operation.) 

Female;  aged  42;  married;  three  children. 

June  3,  1909.  Seeks  relief  for  constant  pain  in  the  left 
side,  above  the  hip,  and  in  the  loin,  which  she  has  had  for 
six  months,  and  can  not  walk  or  work  because  of  it.  Ab- 
dominal section  one  year  before  by  myself  for  hematoma 
of  both  ovaries. 

Abdominal  examination  in  both  dorsal  and  lateral  po- 
sitions showed  both  kidneys  normally  placed.  Muscles 
in  the  left  loin  very  rigid,  and  abdomen  on  same  side  dis- 
tended and  dull  on  percussion.     Patient  sent  to  the  hos- 


EEPOETS  or  CASES. 


191 


pital,  a  cathartic  given,  and  high  enema  used;  examina- 
tion made  imder  ether,  which  was  negative  in  resnlt,  ex- 
cepting that  it  showed  complete  relaxation  and  normal 
condition  of  the  muscles  of  the  loin.  Patient  was  kept 
in  bed  nnder  constant  observation  for  a  week  without 
change  in  the  pain,  which  was  nearly  constant. 

June  29,  1909.  Eadiograph  made,  showing  large  col- 
lection of  gas  at  splenic  flexure  and  complete  ptosis  of 
cecum.     (Fig.  56.) 


Fig-.   56.     Case  il 


Fig-.   57.     Case   4J 


July  1,  1909.  Operation  at  Harper  Hospital.  Nephro- 
colopexy.  Very  long  and  loose  nephrocolic  ligament. 
No  pain  in  the  left  side  after  the  opeiation.  After  three 
weeks  in  bed  and  one  week  up,  went  home.  Abdominal 
supporter  applied  and  petrolatum  oil  prescribed  on  dis- 
charge from  hospital. 

July  28,  1909.  Post-operative  x-ray  (Fig.  57)  shows 
elevation  of  cecum  and  a  tendency  to  the  correction  of  the 
sag  of  the  transverse  colon.  (See  position  of  silver  wire 
suture. ) 


192 


NEPHROCOLOPTOSIS. 


October  3,  1909.  Reports  no  pain  and  is  improving  in 
every  way. 

November  1,  1909.  Reports  by  letter  that  she  has 
gained  ten  pounds  and  is  free  from  pain. 

Case  44. 

Coloptosis  without  nephroptosis.  Intestinal  symptoms 
cured  by  operation. 

Female;  aged  30;  single.   Patient  of  Dr.  C.  G.  Jennings. 


Fig.   58.     Case  44. 


Fig.   59.     Case  44. 


July  7,  1909.  Seeks  relief  for  pain  in  stomach,  com- 
ing on  about  five  hours  after  eating;  severe  constipation, 
from  which  she  has  suffered  nearly  all  her  life — move- 
ments containing  much  mucus;  frequent  attacks  of  pain 
and  sensitiveness  in  right  side  of  abdomen;  pain  passing 
from  the  navel  to  the  rectum;  neurasthenia  and  loss  of 
flesh,  although  she  was  never  very  strong  or  robust. 
Gastroptosis  diagnosticated  by  Dr.  Jennings.  Heart 
normal,  105;  temperature  normal ;  urine  normal.  AVeight, 
one  hundred  pounds. 


REPORTS  OF  CASES.  193 

Abdominal  examination,  in  both  dorsal  and  lateral  po- 
sitions, negative,  excepting  a  very  sensitive  area  around 
McBurney's  point.  (Examine  radiograph  to  determine 
the  viscera  palpated  at  this  point.) 

Vaginal  examination  showed  normal  introitus,  cervix, 
and  uterus.  Behind,  and  at  the  sides  of  the  fundus  uteri, 
two  irregular,  very  sensitive  masses,  large  as  hen's  eggs, 
were  palpated. 

July  11,  1909.  Eadiograph  made  (Fig.  58),  which 
shows  a  complete  coloptosis,  both  the  cecal  end  and  the 
proximal  half  of  the  transverse  portion  lying  nearly  as 
low  in  the  pelvis  as  gravity  can  take  them.  Eadiograph 
of  the  stomach  (Fig.  59)  shows  dilatation  and  moderate 
ptosis.  A  diagnosis  of  coloj)tosis  (without  nephroptosis) 
and  bilateral  ovarian  cystoma  was  made  and  operation 
advised. 

July  15,  1909.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy;  abdominal  section,  with  bilateral  salpingo- 
oophorectomy.  Both  ovaries  contained  large  hemor- 
rhagic cysts.  During  the  operation  the  oozing  from  all 
incised  or  punctured  tissues  was  very  protracted  and 
difficult  to  control.  Both  wounds  healed  perfectly,  and 
recovery  until  the  fourteenth  day  was  practically  afebrile 
and  normal,  excepting  for  rather  more  persistent  pain 
than  usual  in  the  left  side  of  the  abdomen.  On  July  24th 
more  pain  was  complained  of,  and  there  was  a  slight  rise 
of  temperature.  Examination  showed  tenderness  in  the 
left  groin  and  passing  down  the  inside  of  the  thigh  for  a 
few  inches;  and  a  left  phlebitis  developed,  which  was  of 
a  mild  character  and  did  not  extend  further  downward. 
The  treatment  consisted  principally  of  the  application  of 
lead  and  opium  wash  all  the  time,  and  the  ice  bag  during 
any  rise  of  temperature.  At  the  end  of  ten  days  the 
symptoms  had  subsided,  and  patient  was  thinking  of  sit- 


194  NEPHROCOLOPTOSIS. 

ting  up,  when  the  other  side  began  to  show  similar  symp- 
toms and  went  through  a  little  more  severe  course,  the 
affected  veins  reaching  to  the  popliteal  space. 

This  made  a  protracted  convalescence,  and  the  patient 
was  discharged  September  11,  1909. 

October  5,  1909.  Has  gained  some  in  flesh  and  is  be- 
ginning to  feel  stronger.  Bowels  regular  by  the  use  of 
the  oil  and  a  tablespoonful  of  wheat  bran  in  a  glass  of  hot 
water  once  a  day.     Kidney  in  normal  position. 

Case  45. 

Colonic  ptosis  causes  intestinal  toxemia  and  low  febrile 
action  for  years,  with  consequent  progressive  emaciation. 
Cured  by  operation. 

Female;  aged  28;  single;  stenographer. 

December  29,  1904.  Seeks  relief  for  dull  and  constant 
pain  in  lower  abdomen,  which  is  increased  by  sitting  at 
the  desk,  or  standing  or  walking  for  more  than  an  hour 
at  a  time;  jDrogressive  weakness  and  nervous  exhaustion; 
leucorrhea;  loss  of  weight;  feeling  of  feverishness;  mucus 
in  bowel  movements,  which  are  regular,  although  fre- 
quently of  a  diarrheal  character.  Heart  normal,  100; 
temperature,  99°;  lungs  normal;  urine  normal,  excepting 
for  presence  of  amorphous  urates. 

Abdominal  examination  in  dorsal  decubitus  showed 
sensitiveness  at  McBurney's  point;  right  kidney  entirely 
below  the  costal  margin  on  deep  inspiration,  very  mov- 
able and  easily  replaced  manually.  Left  kidney  was  not 
palpable  in  either  position. 

Vaginal  examination  negative. 

Diagnosis  of  nephrocoloptosis,  with  consequent  catarrh 
of  the  colon. 

Silk  elastic  abdominal  band,  with  large  abdominal  pad. 


EEPORTS  OF  CASES.  195 

applied,  and  Enssell's  emulsion  prescribed,  with  direc- 
tions to  flush  the  colon  with  normal  salt  solution  twice  a 
week. 

November  9,  1905.  Pulse,  100;  temperature,  99.2°.  Has 
worn  the  abdominal  supporter  with  a  good  deal  of  relief, 
and  can  work  better  and  be  on  her  feet  longer  with  it. 
Still  has  the  abdominal  pain,  very  severe  at  times;  is 
very  thin,  and  feels  exhausted  all  the  time.  Operation 
advised. 

September  10,  1909.  Married  four  years,  and  has  a 
child  two  and  a  half  years  old.  Says  she  felt  perfectly 
well  for  six  months  before  the  child  was  born,  having 
none  of  the  old  abdominal  pains;  felt  strong,  and  gained 
in  flesh  (caused  by  the  enlarging  uterus  pushing  up  the 
colon  into  its  normal  position,  and  thus  removing  the 
strain  from  the  kidney  and  duodenum).  Kidney  in  com- 
plete ptosis  and  all  the  old  symptoms  have  returned,  and 
the  loss  of  flesh  and  strength  is  at  about  the  limit.  Pa- 
tient emaciated.  Pulse,  105;  temperature  normal;  urine 
normal.     Operation  strongly  advised. 

September  15,  1909.  Operation  at  Harper  Hospital. 
Nephrocolopexy.  Eecovery  ideal  in  every  respect.  Ab- 
dominal supporter,  with  the  truss  attachment,  applied 
and  petrolatum  oil  prescribed  on  discharge  from  hospital. 

December  1,  1909.  Has  gained  five  pounds  since  opera- 
tion; has  good  appetite  and  digestion;  pain  has  entirely 
left  the  abdomen;  bowels  regular.  Kidney  in  normal 
position. 

Case  46. 

Case  having  nephrogastrocoloptosis. 

Female;  aged  33;  single;  stenographer.  Patient  of  Dr. 
C.  G.  Jennings. 

June  30,  1909.     Seeks  relief  for  frequent  attacks  of 


196 


NEPHROCOLOPTOSIS. 


pain  in  the  abdomen  and  a  constant  sensation  of  burning 
in  the  abdomen  and  sides;  indigestion;  insomnia;  can  not 
sleep  on  the  left  side  at  all  because  it  causes  a  sensation 
of  tension  and  fullness,  and  palpitation;  constipation; 
painful  and  irregular  menstruation;  loss  of  flesh.  Had 
ulcer  of  the  stomach  at  14.  Heart  normal,  88;  tempera- 
ture normal;  urine  normal,  except  for  a  sediment  of 
amorphous  urates.  Weight,  eighty-seven  pounds.  Nar- 
row thorax. 


Fig.   60.     Case  46. 

Abdominal  examination  in  dorsal  position  showed 
right  kidney  entirely  below  costal  margin  without  effort, 
and  when  on  the  left  side  it  dropped  somewhat  to  the 
left  of  the  navel. 

Vaginal  examination  negative. 

July  6,  1909.  Eadiograph  made,  showing  entire  ptosis 
of  ascending  and  half  of  transverse  colon  (Fig.  60),  and 
the  stomach  reaching  into  the  pelvis  also.  Operation  ad- 
vised. Abdominal  supporter  applied  and  petrolatum  oil 
prescribed  pending  time  of  operation,  which  was  un- 
certain. 


REPORTS  OF  CASES.  197 

September  10,  1909.  Abdominal  supporter  has  given  a 
good  deal  of  relief  in  adding  to  her  strength  and  endur- 
ance, and  the  oil  causes  better  action  of  the  bowels,  but 
the  pain  and  burning  in  the  abdomen  continue,  and  the 
operation  is  therefore  decided  on. 

September  15,  1909.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  curettage.  Eecovery  without  incident. 
In  bed  eighteen  days. 

November  29,  1909.  Weighs  ninety-three  pounds  (gain 
of  six  pounds) ;  bowels  regular  by  use  of  the  oil  and  oc- 
casionally of  the  enema  also;  no  pain  in  the  left  side. 
Kidney  in  normal  position. 

Case  47. 

A  very  typical  case  illustrative  of  the  obscurity  and 
vagueness  of  the  symptomatology  of  a  coloptosis  and  gas- 
troptosis,  with  very  little  nephroptosis.  After  years  of 
invalidism  cured  by  operation. 

Female;  aged  .31;  married  four  and  a  half  years;  never 
pregnant. 

September  26,  1905.  Seeks  relief  for  frequently  recur- 
ring pain  in  right  side  of  abdomen,  often  very  severe; 
pain  in  the  pit  of  the  stomach  after  eating;  chronic  diar- 
rhea— four  or  five  movements  every  morning;  great  loss 
of  flesh — twenty-five  pounds  in  three  years.  Looks  weak 
and  anemic.  Says  she  has  "spells,"  which  commence 
with  chills,  diarrhea,  severe  vomiting  of  bile,  and  high 
temperature — often  104° — in  which  she  is  very  nervous 
and  hysterical.  Heart  normal,  110;  temperature,  99  1/2°; 
urine  normal. 

Examination  in  both  dorsal  and  lateral  positions  was 
negative,  excepting  for  sensitive  area  around  McBurney's 
point.     ISTeither  kidney  could  be  palpated. 


198  NEPHROCOLOPTOSIS. 

Vaginal  examination  showed  normal  conditions,  ex- 
cepting the  uterns,  which  was  found  to  be  in  a  second  de- 
gree retroversion — mobile  and  easily  replaced  in  the 
knee-chest  position. 

A  diagnosis  was  made  of  chronic  diarrhea  and  intes- 
tinal toxemia;  retroversion  of  the  uterus.  Medicinal  and 
dietetic  treatment  for  the  intestinal  conditions  were  be- 
gun at  once  and  continued  for  a  year  and  a  half,  with 
varying  results.  I  note  that  during  this  time  her  tem- 
perature rarely  registered  below  99°.  She  gave  a  better 
report  from  a  medication  in  which  arsenite  of  copper 
was  used  and  large  doses  of  creosote  were  given,  and 
colonic  flushing  with  normal  salt  solution  used.  I  did  not 
see  her  again  for  a  period  of  over  three  years, 

July  30,  1909.  Has  a  baby  two  and  a  half  years  old, 
and  says  that  while  carrying  the  child  she  felt  perfectly 
well,  having  no  chills  or  fever  or  diarrhea  during  the 
time  (caused  by  the  growing  uterus  pushing  the  colon  up 
in  normal  position,  and  thus  relieving  the  strain  on  the 
kidney  and  duodenum).  The  old  symptoms  began  to  re- 
turn when  the  child  was  six  months  old,  and  have  con- 
tinued to  increase  in  severity  since.  Has  frequent  pas- 
sages, tenesmus,  bearing  down,  etc.,  and  much  mucus  in 
the  stools.  Has  lost  thirty-two  i3ounds  in  two  years,  and 
is  thinner  than  she  ever  was. 

Abdominal  examination  in  the  left  lateral  position,  with 
respiratory  effort,  was  successful  at  this  time  in  bringing 
the  right  kidney  down — only  about  half  of  the  organ  pal- 
pable below  the  costal  margin.  Left  kidney  not  palpable. 
Sensitive  area  in  the  epigastrium  and  down  to  navel. 

Vaginal  examination  showed  a  ruptured  perineum  of 
second  degree;  rectocele;  normal  cervix;  uterus  in  third 
degree  retroversion — easily  replaced  in  knee-chest  po- 
sition. 


REPORTS  OF  CASES. 


199 


August  2,  1909.  Radiograph  made,  showing  the 
stomach  with  the  greater  curvature  three  inches  below 
the  navel  and  the  colon  well  down  in  the  pelvis,  the  cecum 
being  six  inches  below  McBurney's  point.     (Figs.  61,  62.) 

My  abdominal  supporter  applied  and  petrolatum  oil 
and  creosote  prescribed.     Operation  advised. 

September  10,  1909.  Patient  reports  less  abdominal 
pain  while  wearing  the  band,  and  that  it  gives  her  a 
stronger  and  better  feeling.     Diarrhea  less  severe. 


Fig.    61.      Case  47. 


Fig.   62.     Case  47. 


September  25,  1909.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  perineorrhaphy;  Alexander's  operation. 
Recovery  without  incident  until  the  beginning  of  the 
third  week,  when  she  had  several  attacks  of  the  "spells" 
previously  mentioned,  which  always  occurred  at  night 
during  sleep  and  resembled  petit  mal.  In  bed  three 
weeks.     Discharged  from  hospital  October  27,  1909. 

November  27,  1909.  Has  not  had  any  diarrhea  since 
leaving  the  hospital;  bowels  regular;  takes  one  dose  of 
the  oil  daily;  gaining  in  flesh  rapidly — about  ten  pounds; 


200  NEPHROCOLOPTOSIS. 

good    appetite    and    digestion;    sleeps    well;    no    more 
' '  spells. ' ' 

March  10,  1910.  Bowels  continue  normal.  Has  gained 
fifteen  pounds. 

Case  48. 

A  typical  illustration  of  the  progressive  nature  of  the 
colonic  ptosis  in  a  case  under  observation  three  years, 
showing  no  colonic  manifestations  in  its  earlier  liistory, 
but  developing  later  because  of  increasing  distention  and 
angulation  of  the  bowel. 

Female;  aged  22;  married;  two  children,  the  youngest 
1  year  old.     Patient  of  Dr.  D.  J.  Jones. 

September  28,  1906.  Seeks  relief  for  increasing  weak- 
ness; loss  of  flesh  and  nervous  exhaustion;  pain  in  the 
back  of  head  and  in  lower  left  abdomen,  which  she  has 
had  for  several  years.  Is  still  nursing  her  child,  but  has 
irregular,  painful  periods.  Defecation  regular  and  has 
no  mucus  in  stools;  no  leucorrhea.  Heart  normal,  86; 
temperature  normal;  urine  normal. 

Abdominal  examination  in  dorsal  position  shows  right 
kidney  entirely  below  the  costal  margin  without  effort; 
left  kidney  not  palpable;  no  marked  abdominal  ten- 
derness. 

Vaginal  examination  shows  normal  perineum;  erosion 
and  cysts  of  cervix  and  slight  laceration  of  right  side; 
hyperplastic  uterus  in  normal  position  and  mobility;  ap- 
pendages normal;  right  ovary  prolapsed.  Applied  ab- 
dominal supporter,  scarified  cervix,  and  prescribed  tonic. 

October  29,  1906.  Headaches  no  better;  backache  bet- 
ter. Sent  her  to  oculist,  who  prescribed  glasses  for  eye 
strain,  thinking  the  presence  of  astigmatism  the  cause  of 
the  headache. 

February  25,  1907.     Headaches  better. 


REPOETS  OF  CASES.  201 

August  2,  1909.  For  tile  past  two  years  has  been  suf- 
fering more  or  less  with  the  pain  in  the  left  side,  which 
is  now  much  worse.  Is  weak  and  anemic ;  has  indigestion 
and  constipation,  and  notices  much  mucus  and  sometimes 
blood  in  the  stools.  Has  not  worn  the  supporter  for  over 
a  year. 

On  examination  the  right  kidney  was  found  quite  loose 
in  the  abdomen,  and  also  much  sensitiveness  in  left  side 
above  the  hip.  The  pelvic  conditions  were  much  the 
same  as  on  the  previous  examination,  excepting  a  more 
hyperplastic  condition  of  the  uterus.     Operation  advised. 

September  27,  1909.  Operation  at  Harper  Hospital. 
Nephrocolopexy;  curettage;  trachelorrhaphy.  Convales- 
cence good.  In  bed  eighteen  days.  Abdominal  sup- 
porter applied  on  discharge  from  the  hospital. 

November  26.  Bowels  regular  by  the  use  of  the  oil. 
Fears  dislodgment  of  kidney,  as  she  has  had  a  severe 
bronchitis  and  coughed  much  and  violently.  Examina- 
tion showed  the  kidney  in  good  position,  though  the 
lower  pole  could  be  palpated  in  the  left  lateral  position. 

January  10,  1910.     Increasing  in  weight. 

Case  49. 

A  good  example  of  a  case  of  coloptosis  without  nephro- 
ptosis, with  the  usual  history  of  obscure  symptoms  and 
nondiagnosis — later  diagnosis  by  radiography.  Opera- 
tion and  cure. 

Female;  aged  29;  housemaid;  single. 

December  4,  1908.  Seeks  relief  for  pains  in  back,  head, 
hips,  and  abdomen,  which  she  has  had,  gradually  increas- 
ing, for  two  years;  frequent  attacks  of  palpitation,  with 
sudden  awakening  at  night;  constant  constipation,  requir- 
ing use  of  laxatives  and  enemas;  nervousness  and  tremor; 


202 


NEPHROCOLOPTOSIS. 


irregular  painful  menstruation;  leucorrhea  for  several 
years.  Has  had  a  small  goiter  since  she  matured,  but 
never  had  exophthalmus,  and  none  now  in  evidence. 
Heart  normal,  82;  temperature  normal;  urine  normal. 

Abdominal  examination  in  both  dorsal  and  lateral  po- 
sitions negative,  excepting  for  sensitiveness  to  pressure 
at  McBurney's  point  and  just  below  the  navel. 

Vaginal  examination  negative,  excepting  for  a  some- 
what hyperplastic,  retro  verted,  and  flexed  uterus,  which 


Pig-.   63.     Case  49. 


was  freely  mobile  and  easily  replaced  in  the  knee-chest 
position.     Operation  advised. 

December  8,  1908.  Operation  at  Harper  Hospital. 
Curettage;  Alexander's  operation.  In  bed  fourteen  days. 
Good  recovery.  On  discharge  prescribed  petrolatum  oil 
for  the  constipation. 

February  26,  1909.  Still  somewhat  constipated,  and 
needs  the  enema  occasionally  to  assist  the  oil  in  its 
action.  Sleeps  better,  and  has  no  palpitation.  Uterus 
in  normal  position. 


EEPORTS  OF  CASES.  203 

April  6,  1909.  Heavy,  bearing-down  sensation  in  the 
abdomen;  constipation  more  troublesome. 

June  5,  1909.  Complains  of  a  "dragging"  in  the  ab- 
domen.    Uterus  in  good  position. 

September  17,  1909.  Pain  in  back  and  across  ab- 
domen; very  constipated;  oil  and  enema  often  fail  to 
empty  the  bowel,  showing  that  the  fecal  matter  does  not 
reach  the  descending  colon. 

September  2-4,  1909.  Radiograph  (Fig.  63)  shows  the 
cecum  in  the  bottom  of  the  pelvis  and  the  transverse 
colon  greatly  prolapsed,  indicating  a  sharj)  angulation  at 
the  splenic  flexure.     Operation  advised. 

October  2, 1909.  Operation  at  Harper  Hospital.  Neph- 
rocolopexy.  Good  recovery.  In  bed  eighteen  days.  Dis- 
charged October  20,  1909.  Abdominal  supporter  applied 
and  the  use  of  the  oil  continued  as  before  operation.  On 
discharge  weighed  one  hundred  and  thirteen  pounds. 

November  30,  1909.  Weighs  one  hundred  and  twenty- 
one  pounds.  Bowels  regular  by  the  use  of  the  oil  alone. 
Abdominal  pain  relieved. 

February  5,  1910.  Is  perfectly  well;  has  gone  back  to 
work. 

Case  50. 

Case  of  gastrocoloptosis  without  nephroptosis.  Symp- 
toms of  an  obscure  character.  Diagnosis  made  by  radio- 
graph. Operation  restores  normal  nutrition  and  regu- 
lates colonic  function. 

Female;  aged  56;  single.     Patient  of  Dr.  E.  T.  Tappey. 

Patient  treated  for  about  two  years  for  displacements 
of  uterus  and  ovaries,  but  since  the  menopause,  at  50, 
these  conditions  had  not  demanded  much  attention. 

April  20,  1908.  Seeks  relief  for  insomnia;  loss  of  flesh 
— forty  pounds  in  three  years;  progressively  increasing 


204 


NEPHEOCOLOPTOSIS. 


nervous  irritability  and  depression;  fears  loss  of  mind 
(and  looks  it).  Face  drawn  and  distressed;  complexion 
muddy;  bowels  very  constipated  and  movements  attended 
with  pain  in  the  abdomen.  Mucli  pain  in  the  left  side 
over  the  hip — especially  at  night  when  lying — and  often 
has  severe  cramps  of  the  muscles  of  the  thigh  of  this 
side. 

Repeated   examinations   in   various   positions   showed 
both  kidneys  to  be  normally  placed  and  no  other  ab- 


Fig-.    64.     Case  50. 


Case   50. 


dominal  or  joelvic  trouble.  Radiograph  June  20,  1909,  of 
stomach,  and  June  21  of  colon  (Figs.  64,  65)  showed  a 
gastrocoloptosis  of  exaggerated  type. 

July  10,  1909.  Applied  my  abdominal  band  and  pre- 
scribed petrolatum  oil. 

September  16,  1909.  Reports  some  improvement  in 
sleeping  and  bowel  movements;  still  has  abdominal  pain, 
though  less  severe.  Has  gained  three  pounds  since  put- 
ting on  the  supporter,  and  says  it  gives  her  greater  en- 
durance.    Operation  advised. 


EEPOETS  OF  CASES.  205 

October  15,  1909.  Operation  at  Harper  Hospital. 
Neplirocolopexy.  Eecovery  without  incident.  In  bed 
twenty-one  days,  and  during  the  last  fourteen  days  slept 
well,  had  very  little  abdominal  pain,  and  not  any  of  the 
muscular  cramps.  The  usual  daily  enema  of  salt  solution 
caused  the  old  severe  pain  in  the  rectum,  but  when  pre- 
ceded the  night  before  by  an  enema  of  4  ounces  of  warm 
olive  oil  (retained),  the  action  of  the  bowels  by  the  enema 
of  saline  was  natural  and  painless. 

December  4,  1909.  Has  gained  ten  pounds  since  leav- 
ing the  hospital;  gaining  in  strength,  and  sleeps  well. 
The  bowels  move  nearly  in  a  normal  manner  by  the  use 
of  the  petrolatum  oil,  but  about  twice  a  week  there  seems 
to  be  the  same  accumulation — apparently  above  the  sig- 
moid— which  is  dislodged  by  the  use  of  an  enema  to 
overflow  of  an  alkaline  starch  solution  (sod.  bicarb.  3j  to 
Oj).  This  acts  very  kindly  on  the  irritable  bowel,  which 
often  seems  to  be  the  active  etiologic  factor  in  the  in- 
somnia of  these  cases,  and  in  this  instance  it  proves  of 
especial  value,  giving  a  good  night  after  its  use  and  leav- 
ing the  bowel  quiescent  and  free  from  j)ain. 

Case  51. 

Female;  aged  35;  single;  housemaid. 

October  14,  1909.  Seeks  relief  for  severe  dyspepsia; 
catarrh  of  the  bowel;  great  constipation;  backache;  in- 
somnia. 

Had  an  operation,  per  vaginam,  for  uterine  adhesions 
by  another  surgeon  six  months  ago.  Operation  was  fol- 
lowed by  infection  and  she  was  in  bed  two  months  with 
it.     Heart  normal,  80;  temperature  normal;  urine  normal. 

Abdominal  examination  in  the  dorsal  position  was  neg- 
ative, but  in  the  left  lateral  position  the  right  kidney 


206  NEPHEOCOLOPTOSIS. 

dropped  entirely  below  the  costal  margin.  Left  kidney 
in  normal  position  and  not  palpable  in  either  position. 

Vaginal  examination  negative. 

Operation  advised. 

November  9,  1909.  Operation  at  Harper  Hospital. 
Nephrocolopexy.  Eecovery  without  incident.  In  bed 
eighteen  days.  Abdominal  supporter  applied  and  petro- 
latum oil  prescribed  on  discharge  from  the  hospital. 

Case  not  seen  since  discharged  from  the  hospital. 


Case  52. 

Operation  for  coloptosis  without  nephroptosis.  Dilata- 
tion of  cecum  the  cause  of  symptomatology  simulating 
that  of  appendicitis. 

Female;  aged  19;  single;  housemaid.  Ward  patient  at 
Harper  Hospital. 

December  11,  1909.  Referred  to  me  by  Dr.  C.  G.  Jen- 
nings. Was  sent  to  the  hospital  three  days  before  by 
an  outside  physician  for  treatment  for  an  attack  sup- 
posedly of  appendicitis.  Patient  said  she  had  had  three 
previous  attacks  similar  to  this,  the  first  occurring  four 
years  ago,  which  kept  her  in  bed  for  five  weeks;  one  two 
years  ago,  and  one  six  months  afterward,  the  last  two 
each  of  about  three  weeks'  duration.  Said  she  had  chills 
and  fever  with  them,  and  is  certain  she  is  feeling  the  same 
symptoms  with  this  attack.  Her  record  showed  normal 
pulse  and  temperature,  and  normal  urine.  A  blood  ex- 
amination had  been  made,  which  reported  no  leuko- 
cytosis, but  a  marked  lymphocytosis.  Has  had  severe 
constipation  for  four  years,  necessitating  the  habitual  use 
of  enemas  and  cathartics.  Menstruation  irregular,  and 
of  but  four  hours^  duration  each  month.  Has  no  history 
of  any  pelvic  trouble,  and  no  loss  of  flesh.     Complains  of 


EEPOETS  OF  CASES. 


207 


a  stiuging  or  smarting  pain  in  the  right  side  of  the  ab- 
domen, which  she  has  had  ahnost  constantly  since  the 
first  attack  of  "appendicitis"  four  years  ago.  For  the 
last  five  days  has  had  severe  pain  in  the  same  region,  with 
great  sensitiveness.     No  nansea;  bowels  constipated. 

Examination  in  both  dorsal  and  lateral  positions  failed 
to  bring  down  either  kidney,  but  great  sensitiveness  was 
shown  on  palpation  at  McBurney's  jDoint,  and  below  on 
that  side  of  the  abdomen,  which  was  dull  on  percussion. 


Fig.    66.     Case   52. 


The  slightest  touch  caused  the  patient  to  cry  out,  but  the 
board-like  feel  of  muscular  tension  was  absent,  especially 
when  the  patient's  attention  was  attracted  away  from  the 
point. 

Vaginal  examination  was  attempted,  but  failed  because 
of  the  complete  filling  of  the  lower  pelvic  cavity  with 
fecal  matter.  Petrolatum  oil  |ss  twice  daily,  and  a  saline 
enema  morning  and  evening,  were  ordered,  and  the  vagi- 
nal examination  deferred  for  three  days. 

December  14,  1909.     Vaginal  examination  was  nega- 


208  NEPHEOCOLOPTOSIS. 

tive,  exceijting  that  it  showed  the  presence  of  an  infantile 
nterns.  Abdominal  examination  was  again  made,  when 
the  sensitiveness  at  McBurney  's  point  was  found  to  have 
disapj)eared  completely,  and  only  a  slightly  sensitive 
area,  low  in  the  inguinal  region,  was  found.  Eadiograph 
ordered. 

December  15,  1909.  The  radiograph — an  unusual  one, 
showing  the  entire  large  intestine  (Fig.  66) — revealed  the 
trouble.  A  moderate  relaxation  of  the  hepatocolic  liga- 
ment is  shown,  with  descent  of  the  cecum  into  the  pelvis. 
The  cecum  is  seen  to  be  much  elongated  and  dilated, 
which  is  the  condition  that  has  no  doubt  been  causing  the 
constant  smarting  pain,  and  when  acutely  distended,  as  a 
result  of  impaction  farther  along  in  the  large  intestine, 
gave  rise  to  the  acute  symptoms  which  were  thought  to  be 
caused  by  apj)endicitis. 

Operation  of  nephrocolopexy  was  advised,  and  the  con- 
dition explained  to  the  patient,  who  insisted  also  on  ab- 
dominal section  and  the  examination  of  the  appendix. 

December  18,  1909.  Operation.  Nephrocolopexy  and 
appendectomy.  The  nephrocolic  ligament  was  long  and 
lax,  as  previously  noted  in  similar  cases.  The  appendix 
was  found  easily,  through  a  median  incision,  to  be  en- 
tirely normal,  free  from  any  signs  of  irritation  or  de- 
formity, and  its  lumen  pervious.  As  it  was  of  very  large 
size,  being  about  six  inches  in  length,  and  thus  a  possible 
menace  to  her  future  health,  it  was  removed. 

Recovery  without  incident.  Patient  not  seen  since  dis- 
charge, January  10,  1910. 

Case  53. 

Complete  nephrogastrocoloptosis  in  a  male  patient. 

Male;  aged  26;  single;  clerk.  Patient  of  Dr.  C.  G.  Jen- 
nings.    Had  been  treated  by  a  well-known  gastro-enter- 


REPORTS  OF  CASES. 


209 


ologist  for  two  years  and  was  wearing'  an  abdominal 
band,  wliicli  be  reported  bad  benefited  bim. 

December  8,  1909.  Seeks  relief  for  nervonsness;  lack 
of  ability  to  concentrate  bis  tbougbts;  a  severe  constipa- 
tion, wbicb  be  bas  bad  for  several  years.  Says  be  bas  no 
abdominal  pain,  sleeps  well,  and  bas  not  lost  flesb.  Body 
of  tbin  babit,  well  developed;  cbest  broad  and  of  good 
capacity.     Heart,  temperatnre,  and  nrine  normal. 

Abdominal  examination  in  tbe  dorsal  position  sbowed 


Fig-.    67.     Case  53. 


Fig.    68.     Case  53. 


tbe  rigbt  kidney  entirely  below  tbe  costal  margin  witbont 
inspiratory  effort.  In  tbe  left  lateral  position  tbe  kidney 
conld  be  palpated  nnder  tbe  navel.  No  abdominal  sensi- 
tiveness was  fonnd,  excepting  in  tbe  palpated  dropped 
kidney. 

Radiograpbs  of  stomacb  and  large  intestine  sbowed 
extensive  displacement  of  botb  organs  and  dilatation  of 
cecum  and  stomacb.  (Figs.  67,  68.)  Tbe  angulation  of 
tbe  bowel  at  tbe  splenic  flexure  is  sbown  unusuall}^  well, 
tbe  descending  colon  passing  down  close  bebind  tbe  as- 
cending portion  of  tbe  transverse  colon;  tbe  two  ligbt 


210  NEPHEOCOLOPTOSIS. 

spots  indicating  collections  of  gas  at  eitlier  side  of  the 
angulation.  The  showing  would  indicate  complete  re- 
laxation of  the  hepatocolic  ligament.  Operation  advised. 
January  17,  1910.  Operation  at  Harper  Hospital. 
Nephrocolopexy.     Ideal  recovery. 

Case  54. 
Nephrogastrocoloptosis,  in  which  a  gastro-enterostomy 
was  previously  made  because  of  duodenal  occlusion. 

Female;  aged  42;  married;  no  children. 

November  9,  1909.  Seeks  relief  for  profound  neuras- 
thenia; headaches  of  a  joaroxysmal,  violent  character; 
melancholia;  hysteria;  flatulence;  dyspepsia;  pain  in  left 
hypochondrium ;  constipation  and  mucus  in  stools.  Had 
the  operation  of  gastro-enterostomy  made  eight  years  ago 
for  gastroptosis,  with  partial  occlusion  of  the  pylorus, 
which  was  followed  by  some  relief  and  gain  in  flesh.  The 
last  two  years,  however,  she  reports  a  steady  loss  of  flesh 
and  increase  of  nervous  symptoms.  Weight,  eighty-nine 
pounds.  Pulse  slightly  irregular,  100;  heart  normal; 
temperature  98°;  urine  normal. 

Abdominal  examination  in  dorsal  position  showed  well- 
formed  thorax,  thin  and  relaxed  abdominal  walls,  sensi- 
tiveness in  right  loin  at  McBurney's  point.  In  the  left 
lateral  position  the  right  kidney  was  brought  completely 
below  the  costal  margin  on  deep  inspiration,  and  passed 
back  into  the  renal  fossa  when  released. 

Vaginal  examination  was  negative. 

November  17, 1909.  Radiograph  of  the  colon  was  made 
(Fig.  69),  showing  complete  relaxation  of  the  hepatocolic 
ligament  and  descent  of  the  gut  into  the  pelvis.  The  sen- 
sitiveness noted,  on  examination,  at  the  McBurney  point 
is  shown  by  the  radiograph  to  be  located  in  the  dropped 
splenic  flexure,  or  an  angulation  of  the  ascending  colon — 


REPORTS  OF  CASES.  211 

the  entire  cecum  and  appendix  being  below  this  point  in 
the  bottom  of  the  pelvis.  With  this  position  of  the  bowel, 
a  sharp  angulation  at  the  splenic  flexure  would  be  inevit- 
able, and  the  constipation  and  mucus  stools  explained. 
Operation  of  nephrocolopexy  advised. 

January  25,  1910.     Operation  at  Harper  Hospital.     Re- 
covery uneventful. 


Fig-.   69.     Case  54. 

February  22,  1910.  Discharged  from  hospital,  wearing 
abdominal  supporter  and  taking  i^etrolatum  oil. 

March  30,  1910.  Reports  from  Atlantic  City  she  has 
gained  six  pounds. 

Case  55. 

Frequent  child-bearing*  causes  characteristic  symptoms 
of  nephrocoloptosis  to  remain  in  abeyance.  Needle 
wound  of  hilum  of  kidney  causes  temporary  urinary 
fistula. 

Female;  aged  36;  married;  seven  children  in  twelve 
years;  patient  of  Dr.  B.  R.  Shurly. 

Seeks  relief  for  loss  of  flesh — one  hundred  and  forty 
pounds  to  one  hundred  and  thirty  pounds ;  frequent  head- 


212  NEPHROCOLOPTOSIS. 

aches;  backache;  leucorrhea;  weakness  and  nervous  ex- 
haustion. Bowel  movements  always  regular.  Heart, 
temperature,  and  urine  normal.  Says  all  symptoms  have 
increased  gradually  since  the  birth  of  the  last  child,  two 
years  ago. 

Examination  in  the  dorsal  position  showed  thorax 
broad  and  flat;  no  abdominal  tenderness;  right  kidney 
found  at  the  navel  without  deep  inspiratory  effort; 
left  kidney  not  displaced.  Vaginal  examination  showed 
ruptured  perineum  of  second  degree;  extensive  bilateral 
laceration  of  cervix;  endometritis.     Operation  advised. 

February  11,  1910.  Operation  at  Harper  Hospital. 
Right  nephrocolopexy;  perineorrhaphy;  trachelorrhaphy; 
curettage.  Recover}^  uneventful  until  the  twelfth  day, 
when  pain  and  tension  in  the  well-healed  wound  in  the 
loin  was  complained  of.  A  small  incision  was  made  and 
a  drainage  tube  inserted,  from  which  urine  escaped  in 
considerable  quantity  for  one  month,  when  it  gradually 
ceased,  and  the  tube  was  removed. 

April  7,  1910.  Wound  healed,  and  kidney  in  good 
position. 

This  accident  was  undoubtedl}^  caused  by  a  needle 
wound  of  the  renal  pelvis,  which,  with  a  very  mobile  kid- 
ney turned  sideways  to  the  wound,  would  bring  it  close 
enough  to  be  punctured  by  a  deep  needle  insertion.  The 
occurrence  should  warn  the  operator  against  the  unneces- 
sarily deep  insertion  of  sutures  in  this  operation. 

Case  56. 

Appendectomy  advised  by  several  physicians  because 
of  pain  at  McBurney's  point,  caused  by  distention  of  the 
cecum  and  ascending  colon — a  characteristic  symptom  of 
coloptosis. 

Female;  aged  27;  single;  housemaid.  Seeks  relief  for 
loss  of  flesh — one  hundred  and  thirty  pounds  to  one  hun- 


EEPORTS  OF  CASES.  213 

dred  and  thirteen  pounds;  pain  in  right  side  of  abdomen, 
which  is  intensified  by  wallving  or  standing.  Heart,  tem- 
perature, and  urine  normal. 

Examination  in  the  dorsal  position  showed  sensitive- 
ness at  McBurney's  point,  Ijut  nothing  more.  In  the  left 
lateral  position,  deep  respiratory  effort  brought  the  right 
kidney  down  very  low  in  the  abdomen,  where  it  could  be 
moved  about  at  will.  The  left  kidney  could  not  be 
brought  down.  Vaginal  examination  negative.  Opera- 
tion of  nephrocolopexy  advised. 

February  12,  1910.  Operation  at  Providence  Hospital. 
Recoverv  uneventful. 


Summary  of  the  Foreg-oing  Reports  of  Cases, 

on  All  of 

Marr'd 

Suture  mate- 

Chil- 

Diagnosis 

Date  of 

Additional 

rial  used  in 

No. 

Sex 

Age 

or 

single 

dren 

operation 

operations 

nephro- 
colopexy 

1 

F 

26 

M 

1 

Right  nephrocoloptosis ; 
retro versio  uteri;  lacer- 
ated cervix 

Jan. 

8,  1906 

Alexander's  opera- 
tion; trachelorrha- 
phy 

20-day  catgut 

2 

F 

26 

S 

0 

Right  nephrocoloptosis; 
cervical  stenosis 

Jan. 

13,  1906 

Dilatation  cervix 

Same 

3 

F 

27 

M 

1 

Right  nephrocoloptosis; 
ruptured     perineum; 
hemorrhoids 

Feb. 

15,  1906 

Perineorrhaphy; 
Whitehead's  opera- 
tion 

Same 

4 

F 

34 

S 

0 

Right  nephrocoloptosis 

March 

10,  1906 

None 

Same 

5 

F 

28 

s 

0 

Same 

March 

12,  1906 

None 

Same 

6 

F 

29 

s 

0 

Same 

March 

17,  1906 

None 

Same 

7 

F 

31 

M 

1 

Right  nephrocoloptosis ; 
cicatricial  stenosis  os 
uteri 

June 

2,  1906 

Incision;  dilatation 
OS  uteri 

Same 

8 

F 

54 

M 

10 

Right  nephrocoloptosis ; 
varices ;  ruptured  peri- 
neum; lacerated    cer- 
vix 

June 

6,  1906 

Perineorrhaphy ; 
trachelorrhaphy; 
curettage ;    abla- 
tion of  varices 

Same 

9 

F 

27 

S 

0 

Right  nephrocoloptosis; 
endometritis 

July 

6,  1906 

Curettage 

Same 

10 

F 

29 

M 

0 

Right  nephrocoloptosis; 
adhesions 

Sept. 

19,  1906 

Exploratory  abdomi- 
nal section 

Same 

11 

F 

19 

S 

0 

Coloptosis  (without 
nephroptosis) ;  uterine 
polyp 

Sept. 

28,  1906 

Curettage;    extirpa- 
tion of  polyp 

Same 

12 

F 

42 

M 

0 

Right  nephrocoloptosis 

Oct. 

5,  1906 

None 

Same 

13 

F 

32 

M 

3 

Right  nephrocoloptosis; 
lacerated  cervix; 
endometritis 

Oct. 

18,  1906 

Trachelorrhaphy :  cu- 
rettage 

Same 

14 

F 

40 

M 

1 

Right  nephrocoloptosis; 
endometritis 

Oct. 

20,  1906 

Curettage 

20-day  catgut 
silkworm 
gut  in  skin 

15 

F 

42 

S 

0 

Right  nephrocoloptosis; 
uterine  myoma;  adher- 
ent appendix:  retro- 
version 

April 

3,  1907 

Abdominal  section; 
myoToectomy;  ap- 
pendectomy; Alex- 
ander's operation 

20-day  catgut ; 
silver  wire; 
silkworm 
gut  in  skin 

16 

F 

41 

M 

1 

Right  nephrocoloptosis; 
uterine  myoma;  hydro- 
salpinx: appendicitis 

April 

16,  1907 

Abdominal  section; 
myomectomy;  sal- 
pingo-oophorec- 
tomy;    appendec- 
tomy 

Same 

17 

F 

66 

M 

3 

Right  nephrocoloptosis; 
cholelithiasis 

May 

14,  1907 

Abdominal  section; 
cholecystostomy 

.^ame 

18 

F 

26 

M 

0 

Right  nephrocoloptosis 

May 

18,  1907 

None 

Same 

19 

F 

41 

S 

0 

Right  nephrocoloptosis; 
endometritis;  uterine 
myoma 

May 

20,  1907 

Abdominal  section; 
myomectomy; 
curettage 

Same 

20 

F 

28 

S 

0 

Right  nephrocoloptosis ; 
endometritis 

May 

29,  1907 

Curettage 

Same 

21 

F 

31 

s 

0 

Right  nephrocoloptosis; 
hematocystic  ovaries 

June 

21,  1907 

Abdominal  section; 
bilateral  oophorec- 
tomy; curettage 

Same 

22 

F 

36 

M 

1 

Right  nephrocoloptosis; 
lacerated  cervix;  rup- 
tured perineum 

June 

24,  1907 

Trachelorrhaphy; 
perineorrhaphy 

Same 

23 

F 

23 

S 

0 

Right  nephrocoloptosis; 
retroversion;  endome- 
tritis 

June 

29,  1907 

Alexander's  opera- 
tion; curettage 

Same 

24 

F 

30 

M 

0 

Right  nephrocoloptosis; 
endometritis 

July 

5,  1907 

Curettage 

Same 

25 

F 

30 

S 

0 

Right  nephrocoloptosis; 
retroversion;  endome- 
tritis 

Sept. 

20,  1907 

Alexander's  opera- 
tion; curettage 

Same 

26 

F 

41 

M 

4 

Right  nephrocoloptosis 

Sept. 

23,  1907 

None 

Same 

1  Child  born  since  operation;  organs  remain  in  normal  position. 

2  Fall  after  operation  caused  partial  displacement  of  kidney;  did  not  prevent  good  results. 

3  Last  report  states  "occasional  constipation." 

i  Failure  to  improve  symptoms  due  to  neurotic  tendency. 

5  First  case  of  operation  on  case  of  coloptosis  without  nephroptosis:  severe  constipation  cured. 


214 


Which  the  Operation  of  Nephrocolopexy  was  Performed. 


1 

RESULTS 

Bed           T.at.e     1 

No. 

convales- 
cence 

convales- 
cence 

Position  of  kidney 

Defecation 

Weight 

Nervous 
symptoms 

Abdominal 
pain 

1 

Afebrile 

Good 

Normal ;  not  palpable 

Normal 

Increased 

Much  im- 
proved 

Entirely  re- 
lievedi 

2 

Same 

Same 

Same 

Same 

Increased 

Same 

Same 

10  pounds 

j 

3 

Same 

Inter- 
rupted 
by  acci- 
dent 

Two-thirds  palpable     Same 
below  costal  mar- 
gin 

Increased 
21  pounds 

Same 

Same  2 

4 

Septic 

Not  good 

Reported  prolapsed      Not  known 

Not  known       ' 

Not  known 

No  report 

5 

Afebrile    Good 

Normal:  not  palpable 

Normal 

Slight  increase 

Improved 

Improved 

6 

Same         Same 

Same 

Same 

No  report 

Same 

Same 

7 

Same         Same 

Lower  pole  barely 

Same 

Increased 

Much  im- 

Entirely re- 

■ 

palpable  below 

15  pounds 

proved 

lieved 

1 

costal  margin 

8 

Slow;        Slow 

Same 

Same 

Increased 

Improved 

Same 

good  as 

10  pounds 

to  neph- 

roco- 

9 

lopexy 
Afebrile    Good 

Normal;  not  palpable 

Same 

Increased 

Much  im- 

Same3 

12  pounds 

proved 

10 

Same 

Slow  ow- 
ing to 
nausea 

Same 

Same 

No  increase 

No  improve- 
ment 

Improved* 

11 

Same 

Good 

Was  not  displaced 

Same 

Increased 

Much  im- 

Occasional 

15  pounds 

proved 

pain  in 
cecum  due 

to  gaS''' 

12   Same         Same 

Normal 

Nearly  normaMncreased 

Same 

Entirely  re- 

22 pounds 

lieved  6 

13  Same 

Slow 

Lower  pole  barely 
palpable  below  ribs 

Normal 

Slight  increase 

Slightly  im- 
proved 

Improved  7 

14   Good  ex- Same 

Normal;  not  palpable   Same 

Increased 

Much  im- 

Entirely dis- 

cept for 

20  pounds 

proved 

appeared  8 

urinary 

fistula 

15   Good  ex-  Good 

Same                               i Normal:  uses 

Increased 

Same 

Same 

cept 

oil  occasion- 

10  pounds 

pleurisj- 

ally 

10th  day 

16  Good         Slow 

Same 

Same 

Increased 

Same 

Only  occa- 

after 

18  pounds 

sional  pain 

10th        ! 

day         i 

17   Afebrile    |Good 

Same 

Normal 

Increased 

Same 

Entirely  re- 

20 pounds 

lieved 

18  iSIow  duel  Same 

Same                               Same 

Increased 

Same 

Same9 

to  phle- 

8 pounds 

bitis  in 

left  leg 

19   Afebrile 

Same 

Lower  pole  barely         Same 

Increased 

Same 

Same 

palpable  in  left 

26  pounds 

lateral  position 

20 

Same 

Same 

Normal;  not  palpable  ^Same 

Increased 

15  pounds 
Increased 

Same 

Same 

21 

Same 

Same 

Same 

Same 

Same 

Same 

considerably 

22 

Slow; 
good  as 
to  neph- 
roco- 
lopexy 

Same 

Same 

Same 

No  report 

Much  im- 
proved 

Same 

23 

Afebrile 

Same 

Lower  pole  barely 
palpable 

Same 

No  report 

Improved 

Same 

24 

Same 

Same 

Normal ;  not  palpable 

Same 

Increased 
18  pounds 

Much  im- 
proved 

Same 

25 

Same 

Same 

Lower  pole  barely 
palpable 

Same 

Increased 
15  pounds 

Same 

Same 

26 

Septic 

Slow 

Normal;  not  palpable 

Same 

Increased 
35  pounds 

Same 

Same 

6  Had  chronic  diarrhea ;  now  reports  she  has  to  use  an  occasional  enema. 

7  Very  neurotic  and  of  a  uric  acid  diathesis. 

8  Urinary  fistula  occurred  in  wound;  entirely  healed  in  three  months. 

9  Wound  healed  perfectly;  phlebitis  only  in  left  leg. 


215 


Summary  of  the  Foregoing  Reports  of  Cases,  on  All  of 


Suture  mate- 

Marr'd 

Chil- 

Diagnosis 

Date  of 

Additional 

rial  used  in 

No. 

Sex 

Age 

or 

single 

dren 

operation 

operations 

nephro- 

colopexy 

27 

F 

57 

M 

5 

Right  nephrocoloptosis ; 
retroversion;  endome- 
tritis 

Oct. 

12,  1907 

Alexander's  opera- 
tion; curettage 

20-day  catgut; 
silver  wire; 
silkworm 
gut  in  skin 

28 

F 

47 

M 

1 

Right  nephrocoloptosis; 

Dec. 

31,  1907 

None 

Same 

29 

F 

31 

M 

3 

Right  nephrocoloptosis; 
ruptured      perineum; 
retroversion 

April 

17,  1908 

Perineorrhaphy; 
Alexander's  opera- 
tion 

Same 

30 

F 

23 

S 

0 

Right  nephrocoloptosis; 
left  cystic  ovary 

April 

28,  1908 

Abdominal  section; 
left  oophorectomy 

Same 

31 

F 

45 

M 

2 

Right  nephrocoloptosis; 
ruptured     perineum; 
endometritis 

May 

28,  1908 

Perineorrhaphy; 
curettage 

Same 

32 

F 

38 

M 

1 

Right  nephrocoloptosis 

July 

7,  1908 

None 

Same 

33 

F 

30 

M 

3 

Right  nephrocoloptosis; 
retroversion 

Sept. 

30,  1908 

Alexander's  opera- 
tion 

Same 

34 

F 

42 

M 

2 

Right  nephrocoloptosis; 
ruptured     perineum ; 
lacerated  cervix;  en- 
dometritis 

Nov. 

3,  1908 

Perineorrhaphy ; 
trachelorrhaphy ; 
curettage 

Same 

35 

F 

44 

M 

1 

Right  nephrocoloptosis ; 
ruptured     perineum; 
uterine  polyp 

Nov. 

11,  1908 

Perineorrhaphy ; 
excision  of  polyp 

Same 

36 

F 

31 

M 

7 

Right  nephrocoloptosis; 
retroversion;  endome- 
tritis 

Nov. 

28,  1908 

Alexander's  opera- 
tion; curettage 

20-day  catgut; 
silver  wire; 
buried  sub- 
cutaneous 
catgut 

37 

F 

42 

M 

1 

Right  nephrocoloptosis; 
ruptured     perineum; 
endometritis 

March 

4,  1909 

Perineorrhaphy ; 
curettage 

Same 

38 

F 

25 

S 

0 

Right  nephrocoloptosis 

April 

13,  1909 

Dilatation  cervix 

Same 

39 

F 

26 

M 

0 

Right  nephrocoloptosis; 
retroversion 

June 

12,  1909 

Alexander's  operation 

Same 

40 

F 

33 

M 

0 

Right  nephrocoloptosis; 
endometritis 

June 

23,  1909 

Curettage 

Same 

41 

F 

26 

S 

0 

Right  nephrocoloptosis; 
retroversion;  endome- 
tritis 

June 

29,  1909 

Alexander's  opera- 
tion; curettage 

Same 

42 

F 

42 

M 

3 

Coloptosis          (without 
nephroptosis) 

July 

1,  1909 

None 

Same 

43 

F 

30 

S 

0 

Coloptosis          (without 
nephroptosis) ;   cystic 
ovaries 

July 

15,  1909 

Abdominal  section; 
bilaterial  salpingo- 
oophorectomy 

Same 

44 

F 

28 

S 

0 

Right   nephrocoloptosis 

Sept. 

15,  1909 

None 

Same 

45 

F 

33 

S 

0 

Right  nephrogastrocolo- 
ptosis;  endometritis 

Sept. 

15,  1909 

Curettage 

Same 

46 

F 

31 

M 

0 

Right  nephrogastrocolo- 
ptosis;  ruptured  peri- 
neum; retroversion 

Sept. 

25,  1909 

Perineorrhaphy; 
Alexander's  opera- 
tion 

Same 

47 

F 

22 

M 

2 

Right  nephrocoloptosis; 
lacerated  cervix;    en- 
dometritis 

Sept. 

27,  190;j 

Trachelorrhaphy ; 
curettage 

Same 

48 

F 

37 

M 

1 

Right  nephrocoloptosis 

Sept. 

29,  1909 

None 

Same 

49 

F 

29 

S 

0 

Coloptosis         (without 
nephroptosis) 

Oct. 

2,  1909 

None 

Same 

50 

F 

56 

S 

0 

Gastrocoloptosis  (with- 
out nephroptosis) 

Oct. 

15,  1909 

None 

Same 

ai 

F 

35 

s 

0 

Right  nephrocoloptosis 

Nov. 

9,  1909 

None 

Same 

52 

F 

19 

s 

0 

Coloptosis         (without 
nephroptosis) 

Dec. 

18,  1909 

Abdominal  section; 
appendectomy 

Same 

53 

M 

26 

s 

0 

Right  nephrogastrocolo- 
ptosis 

Jan. 

17,  1910 

None 

Same 

54 

F 

42 

M 

0 

Right  nephrocoloptosis 

Jan. 

25,  1910 

None 

Same 

55 

F 

36 

M 

7 

Right  nephrocoloptosis; 
ruptured     perineum; 
lacerated  cervix;  en- 
dometritis 

Feb. 

11,  1910 

Perineorrhaphy ; 
trachelorrhaphy; 
curettage 

Same 

56 

F 

27 

s 

0 

Right  nephrocoloptosis 

Feb. 

12,  1910 

None 

Same 

10  Sleeps  very  much  better. 

11  The  last  case  in  which  the  external  cutaneous. suture  was  used. 


216 


Which  the  Operation  of  Nephrocolopexy  was  Performed. 


I     Bed 
No.  convales- 
cence 


Late 
convales- 
cence 


RESULTS 


Position  of  kidney 


Defecation 


Weight 


Nervous 
symptoms 


Abdominal 
pain 


27 


Septic 


Slow 


Normal;  not  palpable 


Normal 


Increased  Much  im-  Entirely 

25  pounds  proved  relieved 


28 

Afebrile 

Good 

No  report 

No  report 

No  report 

Improved 

No  report 

29  Same 

Same 

Lower  pole  barely         Normal 

Increased 

Much  im- 

Entirely re- 

palpable 

15  pounds 

proved 

lieved 

30  Same 

Same 

Normal;  not  palpable   Same 

Increased 
25  pounds 

Same 

Same 

31  Same 

I 

Same 

Same                              Same 

Increased 

Little  im- 
provement 

Same 

32  Same 

Same 

Entire  kidney  palpa-    Same 

Increased 

Improved 

Still  some  in 

. 

ble,  but  not  mova- 

4 pounds 

both  sides, 

ble 

but  less 
severe  10 

33  Same 

Same 

Normal;  not  palpable   Same 

Increased 

Same 

Relieved 

34   Same 

Slow 

Same                               Same 

Increased 
13  pounds 

Much  im- 
proved 

Improving 

35  Septic 

Same 

Same                                Same 

Increased 
13  pounds 

Improving 

Saraeii 

36   Afebrile 

Good 

Lower  pole  palpable     Same 

Increased 

Much  im- 

Entirely re- 

I 

10  pounds 

proved 

lieved 

37 

Same 

Same 

Normal;  not  palpable   Same 

Increased 

Same 

Same 

32  pounds 

38 

Same 

Same 

Same 

Same 

Increased 
14  pounds 

Same 

Same 

39  Same 

Same 

Same 

Same 

Much  in- 
creased 

Same 

Same 

40  Same 

Same 

Same                                Same 

Increased 

Same 

Same 

i 

14  pounds 

41 

Same 

Same 

Same                             ^Same 

Increased 

Same 

Same 

21  pounds 

42 

Same 

Same 

Not  displaced 

Same 

Increased 

10  pounds 
Increasing 

Same 

Same 

43   Febrile 

Slow 

Normal;  not  palpable   Same 

Improving 

Improving  12 

due  to 

bilateral 

phlebi- 

tis 

44  .Afebrile 

Good 

Same                               Same 

Increased 

Same 

Same 

1 

5  pounds 

45 

Same 

Same 

Same                               ;Improving  by 

Increased 

Same 

Same 

use  of  oil 

6  pounds 

and  enema 

occasionally 

46 

Same 

Same 

Same                                Normal 

Increased 
10  pounds 

Much  im- 
proved 

Entirely  re- 
lieved 

47 

Same 

Same 

Lower  pole  palpable     iSame 

Increasing 

Improving 

Same 

48  iSame 

Same 

Normal;  not  palpable  Same 

Increased 

Same 

Same 

15  pounds 

49  iSame 

i 

Same 

Not  displaced 

Same 

Increased 
8  pounds 

Same 

Same 

50  |Same 

Same 

Same 

Improving 

Increased 
10  pounds 

Same 

Improving 

51  jSame 

Same 

No  report                        No  report 

No  report 

No  report 

No  report 

52   Same 

Same 

Not  displaced                 Same 

Same 

Same 

Samel  3 

53  [Same 

Same 

Normal;  not  palpable   Improving  by 
use  of  oil 

Gaining  rap- 
idly 

Improving 

Relieved 

54 

Same 

Same 

Same                               Normal 

Increased  6 
pounds 

Same 

Improving 

55 

Same 

Slow 

Lower  pole  palpable     Same 

No  increase 

No  report 

No  report 

56 

Same 

Good 

Normal;  not  palpable  |Same 

1 

Increased  2 
pounds 

Improving 

Improving 

12  Wounds  healed  perfectly  by  first  intention. 

13  Appendix  not  diseased,  but  removed  because  of  its  great  size. 

217 


218  NEPHEOCOLOPTOSIS. 

Analysis  of  the  Summary  of  Reports  of  Cases. 

Number  of  cases  of  operation  of  nephrocolopexy  since  Jan- 
uary 8,  1905   56 

Cases  In  which  additional  operations  were  made 38 

Mortality   None 

Results. 
Position  of  the  kidney: 

Normal  (not  palpable  in  any  position) 36 

Slightly  movable   (only  lower  pole  palpable  in  any  po- 
sition)          10 

Loosely  fixed   (not  floating) 2 

Entire  failure  of  fixation  (failure  due  to  sepsis) 1 

Cases  of  coloptosis   (in  which  the  kidney  was  not  dis- 
lodged )    6 

Not  reported    1 

Regulation  of  the  movements  of  the  bowels: 

Normal   (without  medication,  excepting  the  use  of  pet- 
rolatum oil)    48 

Improved 5 

Not   reported    3 

Effect  on  nutrition  as  shown  by  body  weight: 

Increase  of  from  two  to  thirty-five  pounds 38 

Increase    ( amount  not  stated ) 8 

No   increase    2 

Not  reported    8 

Effect  on  the  nervous  system: 

Much   improved    31 

Slightly  improved  and  improving 20 

Not  improved 1 

Not  reported   4 

Effect  on  abdominal  pain: 

Entirely  relieved 35 

Partially  relieved  and  improving 16 

Not  reported    5 

The  most  notable  and  significant  immediate  better- 
ments are  improved  nutrition,  as  shown  by  increase  of 
body  weight — which,  in  some  cases,  is  very  rapid — and 
relief  from  colonic  catarrh,  constipation,  and  the  general 
symptoms  of  colonic  irritability,  as  shown  by  the  regula- 
tion of  the  natural  movements  of  the  bowels. 

Jnst  what  is  accomplished  by  the  fixation  of  the  bowel 
that  leads  to  the  remarkable  improvement  in  the  action 
of  the  colon  has  been  an  interesting  study.  Until  post- 
operative radiographs  were  made  the  author  attributed 
the  improvements  entirelj^  to  the  elevation  of  the  cecum 


EEPORTS  OF  CASES.  219 

and  ascending  colon,  bnt,  as  the  radiograplis— even  in  the 
best  cases  of  recovery — indicate  too  little  change  in  this 
respect  to  be  counted  on  as  the  only  positive  factor,  he 
has  come  to  the  conclusion  that  the  improvement  is 
largely  due  to  the  immobilization  of  the  gut,  caused  by 
the  fixation,  which  acts  as  a  substitute  for  the  relaxed  and 
deficient  or  absent  hepatocolic  ligament.  The  reverse 
peristalsis,  alternating  with  the  forward  peristalsis,  pro- 
ducing the  churning'  action  of  this  part  of  the  colon,  is 
probably  facilitated  by  the  fixation,  as  well  as  the  passage 
of  the  contents  of  the  bowel  over  the  hepatic  flexure. 
The  benefit  to  nutrition  is  attributed  to  the  removal  of 
the  traction  on  the  duodenum  as  well  as  to  the  resumption 
of  the  normal  action  of  the  cecum.  The  neurasthenia  dis- 
appears more  slowly,  but  does  so  surely  as  the  nutrition 
continues  to  improve. 

The  operation,  as  performed  by  the  author,  is  quite  a 
simple  procedure  when  once  the  technic  is  mastered,  and, 
as  is  seen  by  the  foregoing  report,  is  practically  free  from 
danger  to  life.  It  being  made  with  a  minimum  dissec- 
tion and  mutilation  of  the  parts  consistent  with  the  object 
to  be  attained  (the  fixation  of  the  nephrocolic  ligament), 
the  shock  is  comparatively  nil,  and  the  pain  following 
not  of  a  severe  character  and  of  but  a  few  hours'  dura- 
tion. Its  usefulness  in  restoring  the  normal  colonic  func- 
tion in  cases  of  nephrocoloptosis  led  the  author  to  em- 
ploy it  also  in  the  cases  above  reported  of  coloptosis  only. 
While  they  are  of  a  very  limited  number  on  which  to  base 
any  conclusive  deductions,  the  beneficial  results  have 
been  so  immediate  and  positive  that  the  outlook  for  its 
usefulness  in  cases  of  colonic  ptosis  attended  with 
catarrh,  constipation,  or  diarrhea  would  seem  very  good, 
and  warrant  its  farther  application  in  all  such  cases  as  a 
safe  and  efficient  remedy. 


220  NEPHROCOLOPTOSIS. 

Cases  Not  Yet  Come  to  Operation. 

The  following  report  of  cases  wliicli  have  not  yet  come 
to  operation  is  given  for  the  purpose  of  illustrating  valu- 
able points  relating  to  the  text,  and  especially  to  show  the 
diagnostic  jDossibilities  of  the  radiograph,  its  value  being 
strikingly  illustrated  in  some  of  the  cases  of  obscure 
symptomatology. 


Case  A. 

Enormous  dilatation  of  cecum  and  transverse  colon, 
with  complete  nephrocoloptosis. 

Female;  aged  25;  married  one  year;  never  pregnant. 
Patient  of  Dr.  C.  G.  Jennings. 

October  15,  1908.  Seeks  relief  for  neurasthenia;  pro- 
gressive loss  of  flesh — fifteen  pounds  in  a  year;  lack  of 
endurance;  flatulence;  dyspepsia;  backache;  leucorrhea; 
menorrhagia.  The  mother  of  this  patient  had  a  floating 
kidney  all  of  her  adult  life,  but  otherwise  the  family  his- 
tory was  good.  Figure  good  and  thorax  not  of  the  bar- 
rel-shape type.  Heart  normal;  pulse,  100;  temperature, 
98° ;  urine  normal. 

Abdominal  examination  in  the  dorsal  decubitus  showed 
thin  abdominal  walls;  sensitiveness  at  McBurney's  point 
and  in  the  right  inguinal  region;  on  deep  inspiratory 
effort  the  right  kidney  was  brought  entirely  below  the 
costal  margin.  In  the  left  lateral  position  the  kidney 
dropped  below  the  navel.  The  left  kidney  could  not  be 
palpated  in  any  position. 

Vaginal  examination  showed  vagina  and  cervix  normal, 
uterine  bod}^  larger  than  normal,  and  continuous  with  it 
on  the  right  side  a  very  sensitive  tumor,  which  apparently 
consisted  of  the  fallopian  tube  and  ovary  of  that  side  in  a 
condition  of  acute  congestion.     The  pelvic  condition  was 


EEPOETS  OF  CASES. 


221 


treated  by  local  aiitiplilogistics  and  disappeared  entirely 
in  about  six  weeks. 

November  23,  11)08.  A  radiograph  showed  very  ex- 
tensive coloptosis  (Fig.  70)  and  dilatation  of  the  cecum 
and  first  half  of  the  transverse  colon.     The  a])dominal 


Fig-.    70.      Case  A. 

supporter  was  then  applied  and  the  operation  of  nepliro- 
colopexy  advised.  Considerable  relief  followed  the  use 
of  the  supporter — so  much  so  that  the  patient  still  defers 
the  operation. 

Case  B. 
Complete  nephrocoloptosis. 

Female;  aged  32;  single;  teacher.  Patient  of  Dr.  P.  M. 
Hickey. 

January  23,  1909.  Seeks  relief  for  pain  in  left  side  of 
abdomen;  flatulence;  severe  constipation  (for  five  years); 
progressive  emaciation  and  debility;  enlarged  lymphatic 
glands  in  the  neck  were  present,  which  were  suspected  to 
be  tuberculous.  Heart  normal;  temperature  normal; 
pulse,  80;  urine  normal.  Thorax  narrow  and  barrel- 
shaped. 


222 


NEPHEOCOLOPTOSIS. 


Abdominal  examination  in  dorsal  ]Dosition  showed  tym- 
joanitic  fullness  and  sensitiveness  in  left  side;  sensitive- 
ness at  and  below  McBurney's  point;  the  right  kidney 
lying  loose  near  the  navel,  and  could  be  replaced  manu- 
ally up  into  the  renal  fossa.  The  left  kidney  could  not 
be  palpated  in  any  position. 

January  25,  1909.  A  radiograph  of  the  large  intestine 
(Fig.  71)  showed  the  result  of  complete  relaxation  of  the 
hepatocolic  ligament  in  the  descent  of  the  cecum  and 


Fig-.    71.     Case   B. 

transverse  colon  into  the  pelvis  as  far  as  gravity  and  the 
firmly  attached  splenocolic  ligament  would  permit.  The 
radiograph  also  shows  dilatation  of  the  cecum,  and  illus- 
trates well  the  position  of  the  dropped  transverse  colon, 
with  its  sag  to  the  left,  ascending  left  half,  and  conse- 
quent formation  of  an  acute  angle  at  its  junction  with  the 
descending  colon  to  cause  the  sharp  obstructive  angula- 
tion at  the  splenic  flexure.  The  latter  condition  explains 
the  cause  of  the  tympanites  and  pain  complained  of  in 
the  left  side  of  the  abdomen,  which  is  a  characteristic 
symptom  in  cases  of  complete  colonic  ptosis. 


REPORTS  OF  CASES. 


223 


Operation  of  neplirocolopexy  was  advised,  and  arrange- 
ments made  for  tlie  operation,  but  the  date  deferred  from 
time  to  time  because  of  slight  activity  manifested  in  the 
cervical  lymphatic  glands,  and  at  last  given  up  because 
of  the  development  of  pulmonary  tuberculosis. 

Case  C. 

Right  nephrocoloptosis.  Enormous  cecum.  Notable  as 
showing"  no  descent  of  hepatic  flexure. 

Female;  aged  26;  married;  no  children.  Eef erred  to 
me  by  Dr.  L.  Breisacher. 


Fig-.    72.     Case  C. 

January  25,  1909.  Seeks  relief  for  excessive  nervous- 
ness; emaciation;  headaches;  nausea;  frequent  attacks 
of  itching  over  the  entire  body;  constipated  bowels;  gen- 
eral debility.  Can  walk  but  little,  and  spends  much  of 
her  time  on  the  couch.  Heart,  temperature,  and  urine 
normal. 

Examination  in  the  dorsal  position  showed  a  narrow, 
barrel-shaped  thorax,  with  rather  full  abdomen  and  poor 


224  NEPHROCOLOPTOSIS. 

muscular  development;  sensitiveness  over  McBurney's 
point  was  marked,  and  a  lesser  sensitive  point  found  deep 
in  the  pelvis  on  the  left  side.  Neither  kidney  could  be 
palpated  in  that  position.  In  the  left  lateral  joosition  the 
right  kidney  was  forced  below  the  costal  margin  by  the 
inspiratory  effort,  and  was  freely  movable  in  the  region 
of  the  navel.  The  left  kidney  could  not  be  palpated  in 
either  position. 

Vaginal  examination  was  negative. 

June  29,  1909.  A  radiograph  (Fig.  72)  showed  an 
enormously  distended  and  elongated  cecum  and  a 
dropped  transverse  colon,  producing  the  characteristic 
sjDlenic  acute  angle.  This  radiograph  differs  from  all  the 
others  here  shown  in  that  there  is  little,  if  any,  dropping 
of  the  hepatic  flexure  indicated,  and  is  the  only  case  of 
coloptosis  which  I  have  ever  met  with  that  did  not  have 
this  feature.  It  seems  to  be  a  case  similar  to  those  de- 
scribed by  Lane,  in  which  he  advises  complete  extirpa- 
tion of  the  colon. 

The  operation  of  nephrocolopexy  was  advised. 

Case  D. 

Severe  paroxysmal  headaches  caused  by  complete 
nephrocoloptosis. 

Female;  aged  30;  married;  two  children.  Patient  of 
Dr.  Bel  anger. 

January  26,  1909.  Seeks  relief  for  almost  constant 
headache,  which  at  times  becomes  agonizing,  especially 
caused  by  unusual  muscular  effort  or  mental  disturbance; 
constant  pain  in  the  lower  part  of  the  abdomen;  severe 
morning  headache;  much  mucus  in  stools,  which  are  regu- 
lar, but  often  loose,  and  attended  with  pain  in  the  abdo- 
men; pain  in  the  abdomen  also  caused  by  the  act  of  mic- 


REPORTS  OF  CASES. 


225 


turition,  which  is  not  frequent  nor  prodnctive  of  ureteral 
or  vesical  pain;  progressive  loss  of  flesh.  Heart  normal; 
Ionise,  75;  temperature,  98°.  Urine — specific  gravity, 
1,008;  alkaline;  turbid  with  urates. 

Abdominal  examination  in  dorsal  decubitus  showed  a 
narrow  lower  thorax;  flat,  flaccid  abdomen,  sensitive 
across  the  entire  lower  half;  otherwise  negative,  even  the 
inspiratory  effort  failing  to  dislodge  either  kidney.  In 
the  left  lateral   decubitus,   deep   inspiration  forced  the 


Fij 


Case  D. 


right  kidney  quickly  and  entirely  below  the  costal  margin, 
where  it  remained  until  replaced  manually.  The  left  kid- 
ney could  not  be  palpated  in  any  position. 

Vaginal  examination  negative,  excepting  showing 
cervical  endometritis. 

At  the  conclusion  of  the  examination  the  patient  was 
seized  with  one  of  the  characteristic  paroxysms  of  pain 
in  the  head  of  which  she  had  spoken,  and  was  completely 
prostrated  by  it  for  half  an  hour,  holding  the  head  firmly 
in  both  hands   and  pressing  the   forehead   against  the 


226  NEPHROCOLOPTOSIS. 

coucli  while  kneeling  on  the  floor.  She  did  not  cry  out, 
but  moaned,  and  seemed  in  great  agony. 

January  28,  1909.  A  radiograph  (Fig.  73)  showed 
complete  colonic  ptosis,  with  occlusion  at  the  splenic  flex- 
ure and  dilatation  of  the  entire  gut,  the  condition  explain- 
ing the  cause  of  the  constant  pain  in  the  lower  abdomen. 

Nephrocolopexy  was  advised,  but  the  patient  did  not 
return,  and  the  farther  history  of  this  interesting  case  is 
unknown  to  me. 

Case  E. 

Cecal  distention  mistaken  for  appendicitis  for  several 
years. 

Female;  aged  50;  married;  never  pregnant. 

First  treated  this  patient  iq  1893,  when  she  gave  a  his- 
tory of  an  old  tubal  infection,  and  was  then  having  en- 
dometritis, and  occasional  attacks  of  pain  in  the  right 
side  of  the  abdomen,  the  latter  thought  to  be  caused  by 
appendiceal  irritation  of  some  kind.  The  author  treated 
her  for  these  attacks,  which  were  never  attended  with 
rise  of  temperature  or  acceleration  of  pulse,  for  ten  years 
following,  during  which  time  appendectomy  was  pro- 
posed several  times  and  refused.  Each  attack  was  sup- 
posed to  be  fraught  with  danger  of  a  genuine  appendi- 
citis, and  the  patient  was  advised  to  have  the  appendix 
removed  between  attacks.  With  my  present  knowledge 
of  the  symi^tomatology  of  colonic  ptosis  and  the  diagnos- 
tic technic  as  applied  to  nephroj)tosis,  this  patient  would 
not  have  passed  all  of  these  3^ears,  having  attacks  of  pain 
at  the  McBurney  point,  without  the  discovery  of  the  fact 
that  the  appendix  was  far  from  this  supposed  area  of 
its  location,  and  that  the  sensitive  spot  was  really  in  the 
distended  ascending  colon  and  cecum,  or  possibly  in  the 
angulation  caused  by  the  dropping  of  the  hepatic  flexure. 


EEPORTS  OF  CASES. 


227 


This  case  is  a  good  illustration  of  many  similar  ones 
having  supposed  mild  attacks  of  appendicitis,  operated 
on  as  such,  and  perfectly  normal  appendices  removed. 

The  patient  was  lost  sight  of  for  a  number  of  years, 
and  returned  January  27,  1909,  complaining  of  the  same 
old  pain  in  the  side,  and  giving  a  history  of  having  had 
gastric  irritability  and  nausea  for  several  months. 

Abdominal   examination  in   the   left  lateral   position. 


Fig.    74.     Case  E. 


with  inspiratory  effort,  brought  the  right  kidney  well 
down  into  the  abdomen.  The  left  kidney  could  not  be 
dislodged  in  any  position. 

January  29,  1909.  A  radiograph  (Fig.  74)  showed  a 
nearly  complete  coloptosis,  and  located  the  position  of 
the  appendix  much  nearer  the  uterus  than  at  McBurney's 
point. 

Operation  was  advised,  but  has  not  yet  been  decided  on 
by  the  patient. 


228 


NEPHROCOLOPTOSIS. 


Case  F. 

Great  dilatation  of  cecum  and  transverse  colon,  the 
latter  at  the  splenic  flexure. 

Female;  aged  37;  married;  mother  of  four  children. 

February  13,  1909.  Seeks  relief  for  a  burning  sensa- 
tion over  the  entire  abdomen;  quite  constant  pain  in  the 
left  side  above  the  hip;  dryness  of  the  mouth;  alternating- 
constipation  and  diarrhea;  loss  of  flesh  and  strength. 
Heart,  temperature,  and  urine  normal. 


Case  F. 


Abdominal  examination  in  the  dorsal  position  showed 
a  broad,  roomy  lower  thorax;  thin,  flat  abdomen;  sensi- 
tiveness over  McBurney's  point.  Neither  Ividney  pal- 
pable. 

In  the  left  lateral  position  the  right  kidney  was  brought 
down  entirely  below  the  costal  margin  by  inspiratory 
effort.     The  left  kidne}^  could  not  be  dislodged. 

Vaginal  examination  was  negative. 

February  15,  1909.  A  radiograph  (Fig.  75)  showed  a 
comiDletely  dropped  colon;  dilated  cecum,  with  its  lower 


REPORTS  OF  CASES.  229 

end  lying  in  the  bottom  of  the  pelvis,  indicating  the  po- 
sition of  the  appendix  at  this  point;  dilated  transverse 
colon  at  its  partial  occlusion  at  the  splenic  flexure.  The 
angulation  at  the  splenic  flexure  is  doubtless  the  cause  of 
the  pain  above  the  hip,  and  the  burning  sensation  across 
the  abdomen  results  from  the  process  of  dilatation  which 
the  gut  is  constantly  undergoing  because  of  its  inability 
to  force  its  contents  normally  over  this  angulation. 
Operation   advised. 

Case  G. 

A  life  sacrificed  to  a  wrong  diagnosis. 

Female;  aged  36;  married;  no  children;  factory  hand. 

April  21,  1909.  Seeks  relief  for  pain  in  the  left  side 
of  the  abdomen  above  the  hips;  constipation;  weakness 
and  continued  loss  of  flesh — one  hundred  and  thirty-six 
pounds  to  one  hundred  and  twelve  pounds  in  three  years. 
Is  very  nervous  and  can  work  but  about  half  the  time, 
and  often  has  to  leave  her  work  because  of  exhaustion 
and  pain  in  the  side.  Has  large  frame,  broad  chest  and 
abdomen.  Heart  and  temperature  normal;  urine  high 
specific  gravity  and  full  of  urates. 

Abdominal  examination  in  the  dorsal  position  showed 
sensitive  areas  in  the  left  epigastrium  and  right  lumbar 
regions.  Neither  kidney  could  be  forced  below  the  costal 
margin  by  deep  inspiration  while  in  this  position,  but  in 
the  left  lateral  position  the  insjnratory  effort  brought  the 
right  kidney  entirely  below,  where  it  could  he  felt  lying- 
loose,  and  in  the  right  lateral  position  the  left  kidney  was 
brought  partly  below  the  costal  margin  in  a  similar 
manner. 

Vaginal  examination  showed  a  mobile  retroversion  of 
the  third  degree,  which  was  easih^  replaced;  normal 
aclnexa. 


230 


NEPHEOCOLOPTOSIS. 


April  24,  1909.     A  radiograph   (Fig.  76)   showed  the 
complete  ptosis  of  the  bowel. 

Operation  of  bilateral  nephrocolopexy  and  Alexander's 


Fig.    76.     Case   G. 


operation  advised,  and  hospital  arrangements  made,  bnt 
the  patient  songiit  other  advice,  and  died  of  pneumonia 
following  an  abdominal  section  three  weeks  later. 


Case  H. 

Complete  gastrocoloptosis,  with  moderate  nephroptosis. 

Female;  aged  29;  married;  mother  of  three  children. 

June  25,  1909.  Seeks  relief  for  neurasthenia;  progres- 
sive emaciation;  pain  in  the  abdomen  and  ''bearing- 
down;"  constipation;  backache;  dj^spepsia;  nausea.  Be- 
sides bearing  her  children,  during  the  last  seven  years 
she  has  had  a  stormy  operative  career — appendectomy  at 
one  time,  curettage  and  perineorrhaphy  at  another,  and 
an  abdominal  section  for  adhesions  at  last.  A  tubal  in- 
fection a  year  ago  still  further  complicated  the  pathology. 


REPOKTS  or  CASES. 


231 


Has  had  a  daily  rise  of  temperature  of  from  one-lialf  to 
two  degrees  during  the  last  three  years.  Heart  normal; 
pulse,  110;  temperature,  99.2°;  urine  normal. 

Abdominal  examination  in  the  dorsal  position  showed 
a  roomy,  broad  thorax;  sensitiveness  over  the  whole  ab- 
domen, but  especially  at  McBurney's  point,  and  in  the 
median  line  below  the  navel.  Neither  kidney  palpable 
in  this  position.     In  the  left  lateral  position  the  right  kid- 


Fig-.  77.     Case  H. 


Fig-.   78.     Case  H. 


ney  became  entirely  palpable  below  the  costal  margin, 
being  dislodged  by  inspiratory  eifort.  The  left  kidney 
could  not  be  brought  down. 

Vaginal  examination  showed  a  lacerated  cervix; 
normal  uterus;  slightly  enlarged  and  adherent  right  fal- 
lopian tube. 

January  29,  1909.  Eadiographs  of  stomach  and  colon 
(Figs.  77,  78)  showed  extensive  displacement  in  both  in- 
stances. A  more  complete  prolapse  of  the  hepatic  flex- 
ure, as  a  result  of  relaxation  of  the  hepatocolic  ligament, 
is  rarely  seen.     The  appendix,  if  one  were  present,  would 


232  NEPHKOCOLOPTOSIS. 

be  lying  in  the  median  line,  against  the  uterus  or  bladder. 
What  value  would  the  usual  diagnostic  sign  of  pain  and 
tenderness  at  McBurney's  point  have  in  a  case  of  this 
kind  if  attacked  with  appendicitis?  On  the  other  hand, 
how  misleading  is  this  sign  when  applied  to  these  cases, 
almost  all  of  which  have  both  pain  and  sensitiveness  in 
this  region,  caused  by  the  distended  cecal  end  of  the  gut. 
Note  the  distention  in  this  case  of  the  hepatic  flexure, 
which  lies  at  and  below  McBurney's  point. 

An  abdominal  supporter  was  applied,  but  it  caused 
nausea  each  time  that  it  was  worn  for  more  than  an  hour, 
so  that  its  use  was  discontinued  after  a  number  of  per- 
sistent trials.  Adhesions  are  doubtless  present,  as  a  re- 
sult of  the  tubal  inflammation,  and  the  stomach  and  colon 
probably  bound  fast  in  their  present  positions  by  adher- 
ent omentum. 

The  operations  considered  necessary  in  this  case  are 
trachelorrhaphy,  curettage,  abdominal  section,  with  the 
removal  of  the  utering  appendages  and  breaking  up  of 
adhesions,  and  nephrocolopexy.  The  patient  is  now  con- 
sidering such  a  proposition. 

Case  I. 

Enormously  dilated  cecum  and  complete  gastrocolo- 
ptosis  without  nephroptosis. 

Female;  aged  33;  married;  mother  of  two  children. 
Patient  of  Dr.  C.  Gf.  Jennings. 

February,  1906.  I  restored  a  completely  retroverted 
uterus  by  the  Alexander  operation,  and  at  the  same  time 
performed  trachelorrhaj^hy  and  perineorrhaphy.  Since 
that  time  her  second  child  was  born,  the  uterus  and  re- 
paired parts  remaining  intact  thereafter. 

July  12,  1909.     The  patient  returned,  complaining  of 


EEPORTS  OF  CASES. 


233 


frequent  headaches  and  bilious  attacks,  and  soreness  in 
the  right  side  of  the  abdomen;  neurasthenia;  dyspepsia, 
and  loss  of  flesh. 

Abdominal  examination  in  l)otli  dorsal  and  lateral  po- 
sitions failed  to  dislodge  either  kidney,  but,  the  symp- 
toms being  characteristic  of  colonic  or  gastric  ptosis,  a 
radiograph  was  ordered  taken. 

January  14,  1909.  Eadiographs  of  stomach  and  colon 
(Figs.  79,  80)  showed  extensive  gastrocoloptosis,  and  in- 


Fig.    79.     Case   I. 


Fig.    SO.     Case   I. 


dicated  clearly  the  cause  of  the  symptomatology.  Here 
was  a  case  having  a  weak  or  relaxed  hepatocolic  liga- 
ment, allowing  the  hepatic  flexure  to  drop  to  a  point  be- 
low the  level  of  the  navel,  and  having  a  long  nephrocolic 
ligament,  which  prevented  the  usual  renal  displacements. 
The  cecum  is  seen  to  be  ninch  enlarged,  its  distention  be- 
ing doubtless  the  cause  of  the  pain  in  this  side  of  the 
abdomen.  The  cecal  distention  is  the  natural  sequence 
following  the  angulation  at  both  the  hepatic  and  splenic 
flexures,  more  especially  of  the  latter,  which  is  always 
the  most  acute,  and,  being  firmly  fixed  in  its  position,  the 


234 


NEPHKOCOLOPTOSIS. 


backing    up    of    fecal    contents    is    iisnally    from    this 
point. 

Operation  of  neplirocolopexy  was  advised,  but  lias  been 
deferred. 

Case  J. 

Extensive    coloptosis   without    nephroptosis,    causing 
malnutrition  and  emaciation. 

Female ;  aged  30 ;  single.    Patient  of  Dr.  C.  Gr.  Jennings. 

July  30,  1909.     Seeks  relief  for  gradually  increasing 

debility,  neurasthenia,  anemia,  and  loss  of  flesh.    Has  lost 


Fig.    81.     Case   J. 


Fig-.    82.      Case   J. 


thirty  pounds.  "Weighed  one  hundred  and  forty-five 
pounds  at  twenty  years  of  age  and  now  weighs  one  hun- 
dred and  fifteen  pounds.  Sleeps  well  on  either  side,  and 
complains  of  no  indigestion  or  flatulence,  and  bowels  are 
regular.  Menstrual  periods  are  regular,  and  no  symp- 
toms of  pelvic  disease.  Good  figure  and  broad  lower 
thorax.     Heart,  temperature,  and  urine  normal. 

Abdominal  examination  in  both  positions  was  negative, 
excepting  for  sensitiveness  at  McBurney's  point. 


EEPOETS  OF  CASES.  235 

August  2,  1909.  Eadiographs  of  stomacli  and  colon 
(Figs.  81,  82)  showed  dilatation  of  the  stomach  and  ex- 
tensive ptosis  of  the  colon.  The  relaxation  of  the  hepato- 
colic  ligament  is  apparently  complete,  allowing  the  cecal 
end  of  the  bowel  to  descend  into  the  bottom  of  the  pelvis. 
A  long  nephrocolic  ligament  would,  no  doubt,  be  found 
in  this  case  to  account  for  the  kidney  remaining  in  place. 

Operation  was  advised,  but,  as  the  patient  was  just 
starting  for  a  foreign  trip,  she  was  fitted  with  an  ab- 
dominal supporter  and  the  operation  deferred. 

February  .2,  1910.  Reports  much  relief  of  all  symp- 
toms, and  is  still  wearing  the  supporter.  Nutrition  about 
the  same. 

Case  K. 

Nephrocoloptosis  in  its  incipiency  in  a  young  patient, 
pregnant  three  months. 

Female;  aged  25;  married;  never  before  pregnant. 
Patient  of  Dr.  H.  E.  Shaver,  of  Bonnie  City,  Mich. 

October  18,  1909.  Seeks  relief  for  frequent  attacks  of 
pain  across  the  abdomen,  which  is  worse  on  the  left  side, 
above  the  hip,  where  it  commences,  and  afterward  ex- 
tends downward  to  the  bladder;  alternate  severe  consti- 
pation and  diarrhea;  frequent  micturition,  both  night  and 
day;  inability  to  sleep,  excepting  on  the  right  side  (says 
any  other  position  causes  a  choking  sensation) ;  much 
flatulence ;  loss  of  weight — from  one  hundred  and  twenty- 
two  to  one  hundred  and  twelve  pounds.  Says  these  man- 
ifestations have  come  on  gradually  during  the  last  two 
years,  and  are  all  increasing  in  severity  and  persistence. 
Menstruation  always  very  irregular  and  infrequent,  and 
frequently  passes  over  one,  two,  or  three  periods;  none 
since  July  13  last;  no  nausea.     Had  "inflammation  of  the 


236 


NEPHEOCOLOPTOSIS. 


bowels"  at  15,  wliicli  confiiied  lier  to  bed  for  six  weeks. 
Heart  and  temperature  normal ;  urine  slightly  turbid  with 
urates,  otherwise  normal. 

Abdominal  examination  in  the  dorsal  position  showed 
broad  and  roomy  lower  thorax,  tenderness  at  McBurne3^'s 
point,  and  rather  a  fall  abdomen,  with  good  muscular  de- 
velopment. The  inspiratory  effort  failed  to  dislodge 
either  kidney  in  this  position.  In  the  left  lateral  position 
the  inspirator}^  effort  brought  the  right  kidney  down  to 


Fig.   S3.     Case  K. 


84.     Case  K. 


the  paliDating  hand  to  the  extent  of  two-thirds  of  its  vol- 
ume below  the  costal  margin.  The  left  kidney  could  not 
be  palpated  in  either  j^osition. 

Vaginal  examination  showed  a  normal  introitus;  soft 
cervix,  which  was  purple  in  color;  body  of  uterus  soft  and 
enlarged,  reaching  a  i^oint  two  inches  below  the  navel. 

The  patient  was,  no  doubt,  pregnant,  which  would  pre- 
clude any  immediate  surgical  work,  but,  after  conferring 
with  Dr.  Hickey  regarding  the  possible  danger  of  the 
x-ray  to  the  conception,  radiographs  were  made  of  both 


REPOETS  OF  CASES.  237 

stomach  and  colon.  (Figs.  83,  84.)  These  show  a  mod- 
erate displacement  of  both  organs.  The  position  of  the 
transverse  colon,  with  its  sag  to  tlie  left  and  the  sharp 
angle  at  the  splenic  flexnre,  explains  the  cause  of  the  jDain 
in  the  left  side. 

The  case  illustrates  one  of  ptosis  in  comparative  in- 
cipienc}^,  and  one  in  which  results  from  operation  sliould 
be  of  the  best  to  be  obtained  in  this  class  of  cases,  as  the 
gut  has  not  yet  become  chronically  distended.  The 
stomach  has  not  become  much  dilated,  and  will,  no  doubt, 
return  to  its  normal  position  after  the  strain  on  the 
duodenum  has  been  relieved  by  raising  and  fixing  the 
cecal  end  of  the  bowel. 

The  patient  was  advised  to  return  for  operation  after 
confinement  and  the  weaning  of  the  baby.  She  was  as- 
sured that  tlie  symptoms  resulting  from  the  displace- 
ments would  decrease  as  the  pregnancy  progressed,  as  the 
enlarging  uterus  would  push  up  tlie  bowel,  and  thus  re- 
move the  strain  from  the  kidney  and  duodenum  as  well 
as  round  out  the  angle  of  tlie  gut  at  the  splenic  flexure. 

Case  L. 

Enormous  dilatation  of  cecum  and  transverse  colon  due 
to  angulation;  occlusion  at  the  splenic  flexure. 

Female;  aged  28;  factory  hand. 

December  28,  1908.  Seeks  relief  for  pain  in  right  side 
of  abdomen  and  back  on  the  same  side;  severe  headaches, 
which  cause  nausea,  the  attacks  frequentl}"  interfering 
with  her  work ;  irregular  and  painful  menstruation ;  grad- 
ual loss  of  flesh  and  strength;  constipation  and  flatulence 
(gas  has  foul  odor).  Symptoms  have  been  gradually  in- 
creasing for  ten  years.  Has  been  treated  by  many  physi- 
cians for  all  kinds  of  digestive  and  nervous  disorders. 
Heart  normal;  pulse,  68;  temperature  and  urine  normal. 


238 


NEPHEOCOLOPTOSIS. 


Abdominal  examination  in  the  dorsal  position  showed 
a  broad,  roomy  lower  thorax;  flat  abdomen;  good  muscn- 
lar  development;  right  kidney  palpated  in  the  region  of 
the  umbilicns  without  inspiratory  effort,  and  easily  re- 
placed up  behind  the  costal  margin;  no  abdominal  sensi- 
tiveness. 

Vaginal  examination  negative. 


Fig.    S5.     Case   L. 


January  10,  1909.  A  radiograph  of  the  colon  (Fig.  85) 
showed  moderate  coloptosis  and  great  dilatation  of  the 
gut;  the  latter,  no  doubt,  due  to  the  acute  angulation  at 
the  splenic  flexure,  caused  by  the  complete  downward 
drag  of  the  left  end  of  the  transverse  colon  on  the  phreno- 
colic  ligament. 

Abdominal  supporter  applied,  petrolatum  oil  pre- 
scribed, and  operation  advised. 

February  11,  1909.  Reports  partial  relief  of  symp- 
toms.    Operation  deferred. 


REPORTS  OF  CASES. 


239 


Case  M. 

Dietl's  crisis. 

Female;  aged  44;  single.  Patient  of  Dr.  B.  R.  Sliuriy. 
(See  record  of  the  case  in  the  chapter  on  symptoma- 
tology.) 


Fig.   86.     Case   M. 
Bowel    sketched    by    following 
shadow. 


The  radiograph  (retouched  by  the  artist)  shows  a  very 
narrow  thorax  of  the  barrel-shaped  type.  (Fig.  86.) 
Operation  advised,  but  deferred. 


240 


NEPHROCOLOPTOSIS. 


Addendum. 

A  typical,  unfavorable,  anotomic,  and  symptomatic  re- 
sult following-  the  old  operation  of  nephropexy,  confirm- 
ing theory  illustrated  by  Fig.  28. 

This  case,  having  had  symptoms  gradually  increasing 
in  severity  after  a  nephropexy  made  three  years  previous, 
came  to  operation  as  the  book  was  going  to  press.  The 
kidney  was  found  fixed  to  the  muscles  of  the  loin,  about 
two-thirds  of  the  organ  being  below  the  costal  margin. 


Fig.   87. 


Gerota's  capsule  was  in  cicatricial  union  with  the  trans- 
versalis  fascia.  A  portion  of  the  fatty  capsule  was  found 
below  the  lower  pole  of  the  kidney,  to  which  it  was  at- 
tached by  a  few  filaments,  the  most  of  it  passing  down- 
ward to  the  colon.  This  was  raised  up  and  sewed  into  the 
opening  in  the  transversalis  fascia,  hoping  thus  to  retain 
the  elevation  and  cause  the  fixation  of  the  cecum,  the  de- 
scent of  which  had  resulted  in  increased  severity  of  symp- 
toms. 


EEPOKTS   OF    CASES. 


241 


Fig.  87  is  an  x-ray  giving  a  graphic  illustration  of  the 
resultant  complete  coloptosis  following  the  old  operation 
of  nephroioex}^,  in  wliich  the  fatty  capsule  was  stripped 
away  from  the  kidney,  allowing  the  cecal  end  of  the 
gut  to  drop  comjiletely  into  the  pelvic  cavity. 


Fig-.   88. 


Fig.  88  is  a  somewhat  enlarged  radiograph  of  the  same 
case  as  shown  in  Fig.  87,  taken  with  the  patient  in  the 
recumbent  position.  Note  the  higher  position  of  the 
cecum  and  the  separation  of  tlie  lower  part  of  the  loop 
of  the  transverse  colon,  caused  by  the  elevation  of  the 
cecum. 

This  picture  shows  why  the  patient  was  most  comfort- 
able while  recumbent  and  why  she  had  passed  much  of 
her  time  in  bed  during  the  last  three  vears. 


REFEEENCES. 


Alton,  R.  W.,  145 
Belanger,  J.  A.,  224 
Billington,  Wm.,  28 
Blodgett,  Wm.   M.,  15,   82 
Breisacher,  L.,  223 
Burley,  D.  H.,  160 
Burr,  C.  B.,  15,  55 
Cadieux,  H.  W.,  136 
Gary,  Hugh,  143 
Conner,  Sarah,  168 
Duffield,  S.  P.,  172 
Gerota,  39 
Glautenay,    39 
Gleanard,  7,  50 
Gray,  25 

Hickey,  P.  M.,  15,  72 
Huson,  Florence,  131 
Inglis,  David,  154 
Jenne,  B.  H.,  169 
Jennings,  C.  G.,  155 


Jones,  D.  J.,  200 
Kelly-Noble,  25 
Langlois,  F.  J.,  187 
Loucks,  R.  E.,  157 
McGraw,  T.  A.,  181 
Mann,  F.  W.,  146 
Newman,  F.  L.,  139 
Potter,  G.  E.,  137 
Reed,  C.  A.  L.,  28 
Sanderson,  J.  H.,  171 
Shaver,  H.  E.,  235 
Sherrill,  E.  S.,  140 
Shurly,  B.  R.,  60 
Small,  Sidney,  153 
Suckling,  C.  W.,  13,  15 
Tappey,  E.  T.,  203 
Thomas,  O.  J.,  176 
Vernier,  Jean  A.,  163 
Weir-Mitchell,  9 
Zuckerkandl,  39 


213 


INDEX. 


Abdominal  massage,  86 

pad  and  adhesive  plaster,  98,  122 
ptosis,  orthopedic  considerations 
in,  82 
orthopedic  treatment  in,  81,  82 
supporter,  Longyear's,  94 

Long-year's,  adjustment  of,  97, 

98 
Longyear's  elastic,  94 
Longyear's,  in  mechanical 

treatment,  94 
Longyear's,  posture  in  adjust- 
ing, 96 
Acid,  uric,  diathesis  in  medical 

treatment,  87 
Adhesive  plaster.     See  Abdominal 

pad  and  adhesive  plaster. 
Adhesive     plaster,     pad     and,     in 

mechanical   treatment,    98 
After-treatment  in  nephrocolopexy, 

122 
Analysis  of  summary  of  reports  of 

cases,  218 
Anatomic  relations  of  kidneys,  22 
Anatomy,  21 

diagrams  illustrating,  22,  23,  24 
Anesthesia  in  nephrocolopexy,  103 

method  of,  103 
Angulation,     colonic,     in     nephro- 
coloptosis,  51,  54 
colic  caused  by,  55 
of  colon,  27.  31,  51,  54 
of  duodenum,  27,  31,  51,  53 
of  large  intestine,  51,  54 
Antiseptics,  intestinal,  in  medical 

treatment,  90 
Apparatus  necessary  for  Rontgen 

ray,  73 
Appendicitis,  differential  diagnosis 
of,  77 
errors   in   diagnosis   of,   97,   163, 

189,   213 
pain    in    cecum    simulating,    54, 
163,  189,  213 
Appendix,  McBurney's  point  of  no 
value    in   locating,    in    colo- 
ptosis,  182,  193,  199,  203 
Appliances    in    mechanical    treat- 
ment, 92 


Ascending  colon,  44 

attachment  of,  to  kidney  by 
nephrocolic  ligament,  29,  30, 
31 

BiSiSiUTH,      subcarbonate     of,      in 
Rontgen  ray,  73 
subnitrate  of,  in  Rontgen  ray,  73 

Bowels,    regulation   of.     See   Defe- 
cation. 

Bowels,  regulation  of,  after  neph- 
rocolopexy, 126 

Bran  in  constipation,  90 
in  medical  treatment,  90 

Breathing     exercises     in     prophy- 
laxis, 81 

Camppior    stupe    in    topical    treat- 
ment, 91 
Capsule,    fatty,    forming    nephro- 
colic ligament,  25,  29 
fibrous,  25 
Gerota's,  38,  92,  107 
location    of   Gerota's,    important 
in  nephrocolopexy,  107 
Cases,  analysis  of  summary  of  re- 
ports of,  218 
histories    of,    valuable    in    diag- 
nosis, 64 
radiographs  of.   151-241 
reports  of  nonoperative,  220 
of  operative,  130 
of  nephrocolopexy,  130 
summary     of     reports     of,      of 

nephrocolopexy,    214 
value    of    histories    of,    in    diag- 
nosis, 64 
Catarrh,     colonic,     in    nephrocolo- 
ptosis,  55 
mucus    in    stool    indication    of 

colonic,  55 
of   colon,  treatment  of,  87 
Cathartics    in    medical    treatment, 
87 
lubricants  rather  than,  in  medi- 
cal treatment,  88 
to  be  avoided,  87 
Cause,    body   shape    secondary,    of 
nephroptosis,    52 


245 


246 


INDEX 


Cause — cont'd. 

hereditary  laxity  of  restraining 
tissues  primary,  of  nephro- 
coloptosis,  49 

of  rigiit  side  nepliroptosis,  52 
Cecal     pain,     appendicitis     simu- 
lated by,  163,  189,  213 
Cecum,  44,  51 

churning  action  of,  219 

dilatation  of,  59,  226,  228,  232 

displacement  of,  leads  to  faulty 
diagnosis,  54 

pain  in,  simulating  appendicitis, 
54,' 163,  189,  213 

palpation  of,  54 

spastic  contraction  of,  54.  58 
Children,    importance    of    prophy- 
lactic treatment  in,  81,  82 

nephroptosis  in,  13,  86 

orthopedic  treatment   in,   81,   82 

prophylactic  treatment  in,  81,  82 
Colic    caused    by    colonic    angula- 
tion, 55 
by  nephrocoloptOiSis,  55 

in  colon,  55 
Colon,  26,  2v,  30,  31 

angulation  of,  27,  31,  51,  54 

ascending,  44 

attaching  kidney  by  nephrocolic 
ligament  to,  29,  30,  31 

catarrh  of,  55 

colic  in,  55 

descending,  44 

displacement  of,  27,  30,  44 

fixation  of,  of  first  importance 
in  operative  treatment,   100 

fiexures  of,  42 

hepatic  flexure  of,  42 

ligaments  of,  43 

mucus  in  stool  indication  of 
catarrh  of,  55 

ptosis  of,  27,  30,  34 

regulation  of  function  of,  85,  126 

results  of  fixation  of,  218 

sigmoid  flexure  of,  42 

splenic  flexure  of,  42 

stasis  of  contents  of,   85 

transverse,  44 

treatment  of  catarrh  of,   87 
Colonic    angulation,    colic    caused 
by,  55 
in  nephrocoloptosis,  51,  54 

catarrh    in    nephrocoloptosis,   55 

catarrh,  mucus  in  stool  indica- 
tion of,  55 

function.     See  Defecation. 

normal,  function  important  in 
prophylactic    treatment,    85 

pain  in  nephrocoloptosis,  54 


Colonic — cont'd. 

ptosis,     intra-abdominal    fat    to 

prevent,  87 
stasis,    toxemia    caused    by,    55, 
194 
Coloptosis,  27,  30,  44 

causing  nephroptosis,  7,  50 
diagnosis  of,  by  inflation,  69 

by  x-ray,  70 
McBurney's  point  of  no  value  in 
locating    appendix    in,    182, 
193.  199,  203 
nephroptosis  result  of,  7,  50 
olive  oil  in,  90 
petrolatum  oil  in,  88,  126 
symptoms    relieved    by    nephro- 

colopexy,  143,  219 
without   nephroptosis,   cause   of, 
52 
diagnosis   diflScult  in,   65 
nephrocolopexy     in,     10,     143, 
190,   192,   201,   206 
Compression  of  ureter  in  nephro- 
ptosis, 126 
Constipation,  12 
bran  in,  90 

cause  of  ptosis,  51,  86 
caused  by  nephrocoloptosis,    55, 

58 
cured     by     nephrocolopexy,     10, 

143,  190,  192,  201,  206 
fecal  impaction  in,  56 
in  mental  disorders,  56 
olive  oil  in,  90 
persistent     in    nephrocoloptosis, 

58 
petrolatum    oil    in.   88,   126 
treatment  of,  87 
Contraction,     spastic,     of     cecum, 

54,  58 
Corsets,  93 
Crisis.     See    Dietl's   crisis. 

Decubitus,    physical    examination 
in    nephroptosis    in    dorsal, 
66,   67 
in  lateral,   66.   67 
Defecation,     physician's     duty     in 
regulation  of,  86 
regulation  of,  85,  126 
Descending  colon,  44 

kidney,    traction    on    duodenum 
by,  46 
Descensus,  course  of,  50 
Diagnosis,  64,  70 

correct,  necessary.   64 
differential,  76 

of  appendicitis,  77 

of  nephrocoloptosis,  76 


INDEX 


247 


Diagnosis — cont'd. 

difficult     in    coloptosis    without 

nephroptosis,   65 
displacement  of  cecum  leads  to 

faulty,  54 
errors    in,    of    appendicitis,    97, 

163,  189,  213 
histories  of  cases  valuable  in,  64 
importance  of  early,  11 
of  coloptosis  by  inflation,  69 

by  x-ray,  70 
of  nephrocoloptoisis,  64 
physical,  65 

teaching  of  imperfect,  64 
value  of  histories  of  cases  in,  64 

of  symptoms  in,  64 
x-ray  in,  64,  70 
Diarrhea    caused    by    nephrocolo- 
ptosis,   58 
in  nephrocoloptosis,  58 
Diathesis,    uric    acid,    in    medical 

treatment,    87 
Dietl's  crisis,  11,  59 
cases  of,  61,  151,  186 
in   nephrocoloptosis,    11.    59,    61. 

151,  186 
jaundice  in,   60 

preceding    nephrocolopexy,     102 
simulating  peritonitis,  60,   189 
treatment  of,  91 
tympanites  in,  60 
uncertainty  of  attacks  of,  11 
Dilatation   of   cecum,   59,   226,   228, 

232 
Displacement  of  colon,   27,   30,    44 
of  kidneys,  27,  30,   48 
of     kidneys     affecting     morbid 
mentality,  58 
Dissection  to  demonstrate  nephro- 

colic  ligament,  32 
Divisions  of  large  intestine,  43 
Duodenum,  45 

angulation  of,  27,  31,  51,   53 
fixed    position    of,    important   in 

pathology,  45 
suspensory  muscle  of,  26,  31,  45 
traction  on,  by  descending  kid- 
ney,  46 

Electric  pad  in  topical  treatment. 

91 
Eliminatives     in     medical     treat- 
ment,  87 
Enema,  uses  of,  89 

medical  treatment  in,  89 
Enteroptosis,  7 
Etiology,  48 

nephrocolic    ligament    principal 
factor  in,   7,   50 


Etiology — cont'd. 

of  nephroptosis,  48 
Examination,  physical,   in  nephro- 
ptosis   in    dorsal    decubitus, 
66,  67 
in  lateral  decubitus,  66,  67 
technic    of,    of    gastro-intestinal 
tract  by  Rontgen  ray,  72 
Examinations,  percentage  of  neph- 
roptosis in  gynecologic,  14 

Facial   expression   in   nephrocolo- 
ptosis, 58 
Fascia,     perirenal.     See     Gerota'is 
capsule, 
transversalis,  107 
Fat,    intra-abdominal,    to    prevent 
colonic  ptosis,  87 
to   prevent  nephrocoloptosis,    87 
Fatty  capsule  forming  nephrocolic 

ligament,  25,  29 
Fecal    impaction    in    constipation. 

56 
Fibrous  capsule,  25 
Fixation,    adaptability    of    nephro- 
colic ligament  to,  101 
of  colon  of   first  importance   in 
operative  treatment,  100 
results  of,  218 
of  kidney,    effect   of,   on   ureter, 
126 
results  of,  126 
Flexures  of  colon,  42 
hepatic,  42 
sigmoid,  42 
splenic,  42 
Floating  kidney.     See  Nephropto- 
sis. 
Forceps-hook.  Longyear's,  106 
Function   of   colon,    regulation    of, 
85,  126 

Gastro-ixtestinal  tract,  technic  of 
examination  of,  by  Rontgen 
ray,  72 

Gastroptosis,  8.  199,  204,  209,  231, 
233,  234.  237 

Gerota's  capsule,  38,  92,  107 

location   of.   important   in  neph- 
rocolopexy, 107 

Gynecologic  examinations,  p  e  r- 
centage  of  nephroptosis  in. 
14 

Heat  in  topical   treatment,   91 
Hepatic  flexure  of  colon,  42 
Hepatocolic    ligament,    23,    24,    43, 
51,  52 
absence  of,  43 


248 


INDEX 


Hepatoduodenal  ligament,  27,31,52 
Hepatoptosis,  8 

Histories     of    cases    valuable    in 
diagnosis,  64 

Impaction,   fecal,   in   constipation, 

56 
Incision,    location    of,    in    nephro- 

colopexy,  107 
Inflation,    diagnosis    of    coloptosis 

by,  69 
Instruments    used    in    nephrocolo- 

pexy,  104 
Intestinal  antiseptics,  90 
in  medical  treatment,  90 
paresis,    physostigmin    sulphate 
m,  62,  91 
Intestine,  large,  42 
angulation  of,  51,  54 
description   of,   42 
divisions  of,  43 
Intra-abdominal     fat     to     prevent 
colonic  ptosis,  87 

Jaundice  in  Dietl's  crisis,  60 
caused  by   neplirocoloptosis,   54, 
60,  61 

Kidney,  anomalous,  25 

attaching,  by  nephrocolic  liga- 
ment to  colon,  29,  30,  31 

capsule  of,  25,  29 

displacement  of,  27,  30,  48 

affecting  morbid  mentality,  58 

effect  of  fixation  of,  on  ureter, 
126 

elevator,  Longyear's,  103 
used  in  nephrocolopexy,  103 

floating.     See  Nephroptosis. 

moi'bid  mentality  induced  by 
displaced,  58 

palpation  of,  66 

posture  in  palpation  of,  65 

prolapse  of,  in  childhood,  13,  86 

ptosis  of,  27,  30,  48 

results   of  fixation   of,   126 

traction    on    duodenum    by    de- 
scending, 46 
Kidneys,  24 

anatomic  relations  of,  with 
other  organs  and  tissues,  22, 
23,  24 

Ligament,  hepatocolic,   23,   24,  43, 
51,  52 
absence  of,  43 
hepatoduodenal,  27,  31 
nephrocolic,    23,    24,    26,    27,    29, 
31,  32 


Ligament,  nephrocolic — cont'd. 

adaptability    of,     to     fixation, 

101 
attaching  kidney  by,  to  colon, 

29    30   31 
description  of,  29,  32 
discovery  of,  7,  9,  143 
dissection  to   demonstrate,    32 
fatty  capsule  forming,   25,    29 
knowledge     of,      assists      me- 
chanical   treatment,    92 
principal  factor  in  etiology  of 

nephroptosis,  7,  50 
relation's  of,  32 
phrenocolic,    23,    24,    43,   51 
always  present,  51 
utilization    of   Longyear's,    by 
Reed,  28 
Ligaments  of  colon,  43 
Longyear's    abdominal    supporter, 
94 
in  mechanical  treatment,  94 
forceps-hook,  106 
kidney  elevator,   103 
ligament,  utilization  of,  by  Reed, 

28 
operation  of  nephrocolopexy,  102 
Lubricants  rather  than  cathartics 
in  medical  treatment,  88 

McBukney's  point,  76 

of  no  value  in  locating  appendix 
in  coloptosis,  182,  193,  199, 
203 

Malnutrition  caused  by  nephro- 
coloptosis,  54 

Massage,  abdominal,  86 

Mechanical  supports  for  ptosis,  92 

Mechanical  treatment.  See  Treat- 
ment, mechanical. 

Mechanical  treatment,  knowledge 
of  nephrocolic  ligament  as- 
sists, 92 

Medical  treatment.  See  Treat- 
ment,  medical. 

Mental  disorders  caused  by  neph- 
rocoloptosis,  15,  55,  56 
by  ptosis,  15,  56 
constipation  in,  56 
nephroptosis  in,  15,  56 

Mentality,  morbid,  induced  by  dis- 
placed kidney,  58 

Mucus  in  stool  indication  of  co- 
lonic catarrh,  55 

Muscle,  suspensory,  of  duodenum,' 

26,  31,  45 

Nepheocolic  ligament,   23,  24,   26, 

27,  29,  31,  32 


INDEX 


249 


Nephrocolic  ligament — cont'd, 
adaptability   of,  to   fixation,   101 
attaching    kidney    by,    to    colon, 

29,  30,  31 
description  of,  29,  32 
discovery  of,  7,  9,  143 
dissection  to  demonstrate,  32 
fatty  capsule  forming,  25,  29 
knowledge    of,    assists    mechan- 
ical treatment,  92 
principal    factor    in    etiology    of 
nephroptosis,  7,  50 


relations   of,   32 


m, 


Nephrocolopexy,     anesthesia 
103 
after-treatment  in,  122 
constipation    cured   by,    10,    143, 

190,   192,  201,   206 
coloptosis  symptoms  relieved  by, 

143,  219 
Dietl's  crisis  preceding,  102 
in    coloptosis    without     nephro- 
ptosis, 10,  143,  190,  192,  201, 
206 
instruments  used  in,  104 
kidney  elevator  used  in,  103 
location  of  Gerota's  capsule  im- 
portant in,  107 
of  incision  in,  107 
Longyear's  operation  of,  102 
operative  treatment  in,  102 
pad   and   plaster    support    after, 

122,  127 
preparatory  treatment  in,  102 
regulation  of  bowels  after,  126 
reports  of  cases  of,  130 

summary  of,  214 
vomiting  after,   103,  122 
Nephrocoloptosis,  colic  caused  by, 
55 
colonic  angulation  in,  51,  54 
catarrh  in,  55 
pain  in,  54 
constipation  caused  by,  55,  58 

persistent  in,  58 
diagnosis  of,  64 
diarrhea  caused  by,  55,  58 
differential  diagnosis  of,  76 
facial  expression  in,  58 
factors  necessary  to  cause,  50 
hereditary  laxity  of  restraining 
tissues  primary  cause  of,  49 
intra-abdominal    fat   to   prevent, 

87 
jaundice  caused  by,  54,  60,  61 
malnutrition  caused  by,  54 
mental  disorders  caused  by,  15, 

55,  56 
nervous  symptoms  of,  55,  56 


Nephrocoloptosis — cont'd, 
neurasthenia  caused  by,  55 
organs  involved  in,  26,  27,  30,  31 
prevalence  of,  13 
reason  for  the  term,   7 
symptomatology   of,    53 
tachycardia   caused  by,   55 
toxemia  caused  by,  55 
treatment  of,  79 
Nephroenteroptic,       psychopathic, 

symptomatology,  56 
Nephropexy,   failure   of,   in   opera- 
tive treatment,  99 
Nephroptosis,   body  shape   second- 
ary cause  of,  52 
cause  of  coloptosis  without,  52 

of  right  side,  52 
coloptosis  causing,  7,  50 
compression  of  ureter  in,  126 
diagnosis   difficult   in    coloptosis 

without,  65 
Dietl's  crisis  in,  11,  59,  61,  151, 

186 
etiology  of,  48 
in  children,  13,  86 
in  mental  disorders,  15,  56 
nephrocolic    ligament    principal 
factor   in   etiology   of,   7,   50 
physical  examination  in,  in  dor- 
sal decubitus,  66,  67 
in  lateral  decubitus,  66,  67 
percentage  of,  in  gynecologic  ex- 
aminations,  14 
result  of  coloptosis,  7,  50 
torsion  of  pedicle  in,   63 
Nervous  symptoms  of  nephrocolo- 
ptosis, 55,  56 
Neurasthenia,  55 

caused  by  nephrocoloptosis,  55 
Neuroses,  toxemia  a  causative  fac- 
tor in  psychoses  and,  56 
Nonoperative     cases,     reports     of, 
220 

Oil,  olive,  in  coloptosis,  90 
in  constipation,  90 
petrolatum,  in  coloptosis,  88,  126 
in  constipation,  88,  126 
Oils  in  medical  treatment,  88,  90 
Olive  oil  in  coloptosis,  90 

in  constipation,  90 
Operation,  Longyear's,   of  nephro- 
colopexy, 102 
medical    treatment    preparatory 

to.  102 
vomiting  after,  103,  122 
Operative  cases,  reports  of,  130 
Operative    treatment.     See    Treat- 
ment, operative. 


J50 


INDEX 


Organs,    replacement    of,    in    me- 
chanical treatment,   91 
Orthopedic    considerations    in    ab- 
dominal ptosis,  82 
treatment   in   alDdominal    ptosis, 
81,  82 
in   children,   81,   82 
Orthopedics  in  prophylactic  treat- 
ment, 82 

Pad.     See  Abdominal  pad  and  ad- 
hesive plaster. 
Pad   and   adhesive   plaster   in   me- 
chanical treatment,  98 
and  plaster  support  after  neph- 

rocolopexy,  122,  127 
electrical,   in   topical   treatment, 
91 
Pain,  colonic,  in  nephrocoloptosis, 
54 
in    cecum    simulating    appendi- 
citis, 54 
Palpation  of  cecum,  54 
of  kidney,   66 
posture  in,  of  kidney,  65 
Paresis,  physostigmin  sulphate  in 

intestinal,  62,  91 
Pathology,  21 

fixed  position  of  duodenum  im- 
portant in,  45 
Pedicle,     torsion     of,     in     nephro- 
ptosis,  63 
Perirenal  fascia.    See  Gerota's  cap- 
sule. 
Peritonitis,     Dietl's     crisis     simu- 
lating, 60,  189 
Petrolatum    oil    in    coloptosis,    88, 
126 
in  constipation,   88,  126 
Phrenocolic  ligament,  23,  24,  43,  51 

always  present,  51 
Physical    examination    in    nephro- 
ptosis   in    dorsal    decubitus, 
66,    67 
in  lateral  decubitus,  66.  67 
Physician,    duty     of,     in     prophy- 
laxis, 86 
Physostigmin    sulphate    in    intes- 
tinal paresis,  62,  91 
in  medical  treatment,   91 
Post-operative  treatment,  122 

Weir-Mitchell.  9 
Posture,  faulty,  a  factor  in  ptosis, 
82 
in     adjusting     abdominal     sup- 
porter, 96 
in  palpation  of  kidney,  65 
Preparatory  treatment  in  nephro- 
colopexy,  102 


Prevalence  of  nephrocoloptosis,  13 
Prolapse  of  kidney   in    childhood, 

13,  86 
Prophylactic  treatment,  80 
breathing  exercises  in,  81 
duty  of  physician  in,  86 
importance   of,    in   children,    81, 
82 
Psychopathic  nephroenteroptic 

symptomatology,    56 
Psychoses,  toxemia  a  causative  fac- 
tor in,  and  neuroses,  56 
Ptosis,   constipation    cause   of,    51, 
86 
faulty  posture  a  factor  in,  82 
intra-abdominal    fat    to    prevent 

colonic,    87 
mechanical  supports  for,  92 
mental  disorders  caused  by,  15, 

56 
of  colon,  27,  30,  34 
of   kidney,   27,   30,   48 
orthopedic    ,  treatment     in     ab- 
dominal, 81,  82 

Radiographs,    directions    for    pre- 
paring  patients   for,    71,    74 
of  cases,  151-241 
Replacement     of    organs     in     me- 
chanical treatment,  91 
Reports  of  cases.     See  Cases. 
Rontgen  ray,  apparatus  necessary 
for,  73 
powerful      modern,      equipment 

necessary,   75 
subcarbonate  of  bismuth  in,  73 
subnitrate  of  bismuth  in,  73 
technic   of   examination    of  gas- 

tro-intestinal   tract  by,   72 
zirconium  oxide  in,  74 

Sigmoid  flexure  of  colon,  42 

Spastic  contraction   of  cecum,   54, 
58 

Splanchnoptosis,  7 

Splenic  flexure  of  colon,  42 

Stasis  of  contents  of  colon,  85 
toxemia    caused   by    colonic,    55, 
194 

Stomach,  46 

Stool,     mucus     in,     indication     of 
catarrh   of  colon,   55 

Stupe,    camphor,    in    topical   treat- 
ment, 91 

Subcarbonate    of    bismuth    in 
Rontgen  ray,  73 

Subnitrate      of      bismuth      in 
Rontgen  ray,  73 

Summary  of  reports  of  cases,  214 


IXDEX 


251 


Support,    pad    and    plaster,    after 

nephrocolopexy,  122,  127 
Supporter,    abdominal.     See    Ab- 
dominal  supporter. 
Supports,    mechanical,    for    ptosis, 

92 
Suspensory   muscle   of  duodenum, 

26,   31,   45 
Symptomatology,   53 
of  nephrocoloptosis,   53 
psychopatbic     nephroenteroptic, 
56 
Symptoms,  coloptosis,   relieved  by 
nephrocolopexy,   143,   219 
nervous,  of  nephrocoloptosis,  55, 

56 
value  of,  in  diagnosis,  64 

Tachycardia    caused    by    nephro- 
coloptosis, 55 
Topical    treatment.     See    Treat- 

ment,  topica!. 
Torsion     of     pedicle     in     nephro- 
ptosis, 63 
Toxemia     a     causative    factor    in 
psychoses  and   neuroses,   56 
caused  by  colonic  stasis,  55,  194 
by  nephrocoloptosis,  55 
Transversalis  fascia,  107 
Transverse   colon,   44 
Treatment,  79 

breathing    exercises    in    prophy- 
lactic, 81 
duty    of    physician    in    prophy- 
lactic, 86 
importance    of    prophylactic,    in 

children,  81,  82 
knowledge    of    nephrocolic    liga- 
ment assists  mechanical,  92 
of  catarrh  of  colon,  87 
of  constipation,  87 
of  Dietl's  crisis,  91 
of   nephrocoloptosis,   79 
mechanical,   91 
appliances  in,  92 
elastic     abdominal     supporter 

in,  94 
Longyear's      abdominal      sup- 
porter in,  94 
orthopedic,  81,  82 
pad    and   adhesive   plaster    in, 

98 
replacement  of  organs,   91 
medical,  87 
bran  in,  90 
cathartics   in,   87 


Treatment,  medical — cont'd. 

eliminatives   in,   87 

in  enema,  89 

intestinal   antiseptics   in,   90 

lubricants  rather  than  cathar- 
tics in,  88 

oils  in,   88,  90 

physostigmin    sulphate    in,    91 

preparatory  to  operation,   102 

uric  acid  diathesis  in,  87 
operative,  99 

failure  of  nephropexy  in,  99 

fixation   of   colon   of  first   im- 
portance   in,    100 

in   nephrocolopexy,   102 
orthopedic,  in  abdominal  ptosis, 
81,   82 

in   children,  81,   82 
post-operative,  122 

Weir-Mitchell,  9 
preparatory,   in  nephrocolopexy, 

102 
prophylactic,   80 

duty  of  physician  in,  86 

in  children,  81,  82 

normal    colonic    function    im- 
portant in,   85 

orthopedics    in,    82 
topical,  91 

camphor  stupe  in,  91 

electric  pad  in,  91 

heat  in,    91 

hot  water  bag  in,  91 

working  basis  for,  8 
Tympanites  in  Dietl's  crisis,  60 

Uric  acid  diathesis  in  medical 
treatment,    87 

Ureter,  compression  of,  in  nephro- 
ptosis,   126 
effect  of  fixation  of  kidneys  on. 
126 

Vomiting  after  nephrocolopexy, 
103,  122 

Water  bag,  hot,  in  topical  treat- 
ment,  91 

Weir-Mitchell  post-operative  treat- 
ment, 9 

X-RAY  in  diagnosis,  64,  70 

diagnosis  of  coloptosis  by,   70 

ZiRCOjSfii'M  oxide  in  Rontgen  ray, 
74 


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